UPDATED INSTRUCTIONS for the CMS-1500 08/05 Version

May 14, 2007

UPDATED INSTRUCTIONS FOR THE CMS-1500 08/05 version.

The National Uniform Claim Committee (NUCC) posts the complete instruction manual for the CMS-1500 08/05 version on its web site. The web address is www.nucc.org.

The most significant changes are explained here. Refer to the sample CMS-1500 08/05 version posted here.

NOTE: The NUCC instructions are generic in nature. Various third party payers, i.e. Blue Cross/Blue Shield, and other commercial carriers, may have specific or slightly different requirements.

GENERAL INSTRUCTIONS

Each line of the CMS-1500 08/05 version has a shaded and unshaded area. The shaded areas are used to enter additional or supplemental information, such as anesthesia start and stop times.

The unshaded areas are used in the same manner as the CMS-1500.

Blocks that require provider or facility ID numbers are divided by NPI and non- NPI identification numbers. The NPI is always required. The non-NPI number may not be required. The non-NPI number is an identification number that is unique to a specific insurance plan or program.

TOP OF THE FORM

In the white space at the top of the form enter the name, address, city, state, and zip code of the recipient of the CMS-1500 08/05

EVERYBODYS INSURANCE INC 123 PAYDAY AVENUE ANYWHERE AK 123456

BLOCK 1 TRICARE has been added to the CHAMPUS box.

BLOCK 1a through BLOCK 17 No change. BLOCK 17a. (Shaded Area) The section immediately to the right of 17a. is the qualifier field. The remainder of 17a is used to enter the non-NPI number of the provider named in 17.

The qualifier indicates what the number in the block 17a represents. Qualifiers include:

0B State License Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number E1 Employer’s Identification Number G2 Provider Commercial Number LU Location Number N5 Provider Plan Network Identification Number SY Social Security Number (May not be used for Medicare) X5 State Industrial Accident Provider Number ZZ Provider Taxonomy

Example: 17a. 0B 456789A This entry means the State License Number for the provider named in 17 is 456789A.

BLOCK 17b. Enter the 10 digit NPI number for the provider named in 17.

BLOCK18 through BLOCK 23 No change.

BLOCK 24 A. No change. Enter the dates in the unshaded area.

BLOCK 24B. No change.

BLOCK 24C. The block is renamed to EMG. Type of Service is deleted.

Enter Y or N in the unshaded area, to indicate whether or not the services provided were related to a medical emergency. See instructions for Block 24I, page 280 in the text. BLOCK 24D. No change.

BLOCK 24E. Renamed DIAGNOSIS POINTER. Enter the reference number (1 through 4) of the ICD-9-CM diagnosis code in block 21 that best justifies the medical necessity for the procedure identified in block 24D. More than one reference number may be entered in Block 24E, unless specific insurance company instructions are different.

BLOCK 24F through 24H. No change. Enter information in unshaded areas.

Block 24I. Renamed: ID QUAL.

Shaded area is the non-NPI qualifier. The qualifier indicates what the number in the shaded area of block 24J represents. Qualifiers include:

0B State License Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number E1 Employer’s Identification Number G2 Provider Commercial Number LU Location Number N5 Provider Plan Network Identification Number SY Social Security Number (May not be used for Medicare) X5 State Industrial Accident Provider Number ZZ Provider Taxonomy

Example: 21I. 0B This entry means the entry in 21J is the State License Number for the provider who rendered the service.

The unshaded area is preprinted with NPI. This means the entry in 21J is the NPI number for the provider who rendered the service.

BLOCK 24J. Combined with block 24K and renamed: RENDERING PROVIDER ID. #.

Shaded area: Enter the non-NPI identification number of the provider who rendered the service.

Unshaded area: Enter the NPI number of the provider who rendered the service. BLOCK 25 through 31. No change.

BLOCK 32, 32a, and 32b. Renamed: SERVICE FACILITY LOCATION INFORMATION.

Enter the name, address, city, state, and zip code of the location where the services were provided i.e., hospital, outpatient facility. Also used for the name, address, zip code and NPI number of the service provider/facility associated with the charges entered in block 20.

32a. Enter the NPI number of the service facility location named in 32.

32b. Enter the qualifier and non-NPI identification number of the service facility location named in 32.

Note: ID Qualifiers are the same as those listed for Block 24J

BLOCK 33, 33a, and 33b. Renamed: BILLING PROVIDER INFO & PH #

This block identifies the provider that is requesting to be paid for the services rendered and should always be completed.

1st Line: Name 2nd Line: Address 3rd Line: City, State, and Zip Code

The phone number is entered in the area to the right of the block name.

33a. Enter the NPI number of the billing provider. This is the NPI number of the provider that is requesting to be paid for the services rendered.

33b. Enter the qualifier and non-NPI identification number of the billing provider.

Note: ID Qualifiers are the same as those listed for Block 24J