Module 1: CMS 1500 Form

Question 1

section 1

Answer 1

carrier block, contains the address of the insurance carrier, located at the top of the form

Question 2

section 2

Answer 2

patient and insured section, contains information about the patient or insured, boxes 1-13

Question 3

section 3

Answer 3

physician and supplier section, contains information about the physician or supplier, boxes 14-33

Question 4

boxes 1-8

Answer 4

type of insurance, insured info, patient info

Question 5

boxes 9-13

Answer 5

primary and secondary insurance info, plan names and ID numbers, what illness is related to

Question 6

boxes 14-18

Answer 6

date of current illness, referring/ordering provider info (NPI)

Question 7

boxes 19-23

Answer 7

diagnosis codes, outside labs and charges

Question 8

boxes 24A-J

Answer 8

dates of service, CPT/service codes and charges

Question 9

boxes 25-33A

Answer 9

federal tax ID, patient account number, total charges, amount paid, doctors signature, service facility info, billing provider info

Question 10

DN qualifier

Answer 10

referring provider, the physician who requests the service for the patient

Question 11

DK qualifier

Answer 11

ordering provider, a physician or non physician who orders non physician services for the patient; these services include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment

Question 12

DQ qualifier

Answer 12

supervising provider, the physician monitoring the patient’s care

Question 13

NPI number

Answer 13

a unique identification number for all HIPAA-covered entities, including individuals, organizations, home health agencies, clinics, nursing homes, residential treatment homes, laboratories, ambulances, group practices, and health maintenance organizations (HMOs)