CMS-1500 Flashcards
Fields 1-13
Patient demographic information
Block 4
If there is a primary insurance other than Medicare from the patient or the spouses place of work list the name of the insured.
Block 10a-c
Indicate if there is employment, auto liability, or other accident involvement
Block 11
Place to indicate that a good faith effort has been made to determine if Medicare is the primary
Block 12
Where the patient signs to authorize the release of medical information.
Block 13
Signature authorizing payment of benefits to the physician or supplier. If not signed then payment goes to the patient.
Block 14
Date of illness or injury
Block 16
Dates that patient is unable to work - this is required for disability or workers comp benefits
Block 17
Name of referring physician
Block 17b
NPI # of referring physician
Block 20
Were labs done outside of the billing facility, yes or no
Block 21
Diagnosis codes go here
Block 23
Prior authorization # goes here
Block 24a
Dates of service
Block 24b
Where places of service codes go
