Block 1 Type(s) of Health Insurance - Indicate coverage applicable to this claim by checking the appropriate block(s).
Block 1A Insured’s I.D. Number - Enter the member’s Blue Cross and Blue Shield identification number, including their three-character alpha prefix, exactly as it appears on the identification card.
Block 2 Patient’s Name - Enter the full name of the individual treated.
Block 3 Patient’s Birth Date - Indicate the month, day and year. Sex - Place an X in the appropriate block.
Block 4 Insured’s Name - Enter the name from the identification card except when the insured and the patient are the same; then the word “same” may be entered.
Block 5 Patient’s Address - Enter the patient’s complete, current mailing address and phone number.
Block 6 Patient’s Relationship to Insured - Place an X in the appropriate block. Self - Patient is the member.
Block 6 Spouse - Patient is the member’s spouse. Child - Patient is either a child under age 19 or a full-time student who is unmarried and under age 25 (includes stepchildren). Other - Patient is the member’s grandchild, adult-sponsored dependent or of relationship not covered previously.
Block 7 Insured’s Address - Enter the complete address; street, city, state and zip code of the policyholder. If the patient’s address and the insured’s address are the same, enter “same” in this field.
Block 8 Reserved for NUCC USE - This section is reserved for NUCC use. Deleted “Patient Status” and content of field.
Block 9 Other Insured’s Name - If the patient has other health insurance, enter the name of the policyholder, name and address of the insurance company and policy number (if known).
Block 10 Is patient’s condition related to: a. Employment (current or previous)?; b. Auto Accident?; c. Other Accident?. Check appropriate block if applicable.
Block 11 Not required.
Block 11D When appropriate, enter an X in the correct box. If marked “YES”, complete 9, 9A and 9D.
Only one box can be marked.
Block 12 Patient’s or Authorized Person’s Signature - Appropriate signature in this section authorizes the release of any medical or other information necessary to process the claim. Signature or “Signature on File” and date required. “Signature on File” indicates that the signature of the patient is contained in the provider’s records.
Block 13 Insured’s or Authorized Person’s Signature - Payment for covered services is made directly to participating providers. However, you have the option of collecting for office services from members who do not have a copayment benefit and having the payments sent to
the patients. To receive payment for office services when the copayment benefit is not applicable,
Block 13 must be completed. Acceptable language is:
a. Signature in block d. Benefits assigned
b. Signature on file e. Assigned
c. On file f. Pay provider
Please Note: Assignment language in other areas of the CMS-1500 claim form or on any attachment is not recognized. If this block is left blank, payment for office services will be sent to the patient. Completion of this block is not necessary for other places of treatment.
Block 14 Date of Current - Enter the first date of illness, injury or pregnancy filed on claim- Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY) date of the first date of the present illness, injury, or pregnancy. for pregnancy, use the date of the last menstrual period (LMP) as the first date.
Block 15 Enter another date related to the patient’s condition or treatment. Enter the date in the 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY) format. Enter the applicable qualifier to identify which date is being reported.
Block 16 Dates Patient Unable to Work in Current Occupation - Enter dates, if applicable.
Block 17 Name of Referring Provider or Other Source - Enter the name ( First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim. If multiple providers are involved, enter one provider
using the following priority order:
1. Referring Provider
2. Ordering Provider
3. Supervising Provider
Do not use periods or commas. A hyphen can be used for hyphenated names. Enter the qualifier to the left of the vertical, dotted line.
Block 17A Other ID#. The non-NPI ID number of the referring physician, when listed in Block 17.
Block 17B NPI – Required. Enter the national provider identifier (NPI) for the referring physician, when listed in Block 17.
Block 18 For Services Related to Hospitalization - Enter dates of admission to and discharge from hospital.
Block 19 (Designated by NUCC) - Additional Claim information to be completed by NUCC.
Block 20 Laboratory Work Performed Outside Your Office - Enter, if applicable.
Block 21 Diagnosis or Nature of Illness or Injury- Enter the applicable ICD indicator to identify which version of ICD codes is being reported: “9” for- ICD-9-CM or “0” for ICD-10-CM codes- Note: All transactions, electronic or paper-based, for services on and after October,
1, 2015, must contain ICD-10 codes or they will be rejected. Blue Cross will not accept ICD- 9 codes with dates of services on or after October 1, 2015. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to
identify the patient’s diagnosis and/or condition. List no more than 12 ICD-9-CM or ICD-10- CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.
Block 23 Prior Authorization Number- Enter the authorization number obtained from Blue Cross/ HMO Louisiana, if applicable.
Block 24A Date(s) of Service - Enter the “from” and “to” date(s) for service(s) rendered.
Block 24B Place of Service - Enter the appropriate place of service code. Common place of service codes are:
Inpatient - 21 Outpatient - 22 Office - 11
Block 24C EMG - Enter the Type of Service code that represents the services rendered.
Block 24D Procedures, Services, or Supplies - Enter the appropriate CPT or HCPCS code. Please ensure your office is using the most current CPT and HCPCS codes and that you update your codes annually. Append modifiers to the CPT and HCPCS codes, when appropriate.
Block 24E Diagnosis Pointer - Enter the diagnosis code reference letter (pointer) as listed in Block 21 to relate the date of service and the procedures performed to the primary diagnosis.
When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. ICD-10-CM diagnosis codes must be entered in Block 21 only. Do not enter them in 24E.
Block 24F Charges - Enter the total charge for each service rendered. You should bill your usual charge to Blue Cross regardless of our allowable charges.
Block 24G Days or Units - Indicate the number of times the procedure was performed, unless the code description accounts for multiple units, or the number of visits the line item charge represents. Base units value should never be entered in the “units” field of the claim form.
Block 24J Rendering Provider ID# - Enter the national provider identifier (NPI) for the rendering physician for each procedure code listed when billing for multiple physicians’ services on the same claim. Laboratory, Durable Medical Equipment, Emergency Room Physicians,
Diagnostic Radiology Center, Laboratory and Diagnostic Services, and Urgent Care Center providers do not have to enter a physician NPI in this block. Please enter the facility NPI in blocks 32A and 33A as instructed.
*Rural health clinics and Federally Qualified Health Centers are required to enter the rendering provider NPI.
Block 24K Expand claim line to report NDC, Quanitity, and Measurement.
Block 25 Federal Tax I.D. Number - Enter the provider’s/clinic’s federal tax identification number to which payment should be reported to the Internal Revenue Service.
Block 26 Patient’s Account Number - Enter the patient account number in this field. As many as nine characters may be entered to identify records used by the provider. The patient account number will appear on the Provider Payment Register/Remittance Advice only if it
is indicated on the claim form.
Block 27 Accept Assignment - Not applicable - Used for government claims only.
Block 28 Total Charge - Total of all charges in Item F.
Block 29 Amount Paid - Not required.
Block 30 Not required.
Block 31 Signature of Provider - Provider’s signature required, including degrees and credentials.
Block 32 Name and Address of Facility - Required, if services were provided at a facility other than the physician’s office.
Block 32A NPI - Enter the NPI for the facility listed in Block 32.
Block 32B Other ID. The non-NPI number of the facility refers to the payer-assigned unique identifier of the facility.
Block 33 Billing Provider Info & Ph# - Enter complete name, address, telephone number for the billing provider.
Block 33A NPI - Enter the NPI for the billing provider listed in Block 33.
Block 33B Other ID#. The non-NPI number of the billing provider refers to the payer-assigned unique identifier of the professional.
Block 1A Insured’s I.D. Number - Enter the member’s Blue Cross and Blue Shield identification number, including their three-character alpha prefix, exactly as it appears on the identification card.
Block 2 Patient’s Name - Enter the full name of the individual treated.
Block 3 Patient’s Birth Date - Indicate the month, day and year. Sex - Place an X in the appropriate block.
Block 4 Insured’s Name - Enter the name from the identification card except when the insured and the patient are the same; then the word “same” may be entered.
Block 5 Patient’s Address - Enter the patient’s complete, current mailing address and phone number.
Block 6 Patient’s Relationship to Insured - Place an X in the appropriate block. Self - Patient is the member.
Block 6 Spouse - Patient is the member’s spouse. Child - Patient is either a child under age 19 or a full-time student who is unmarried and under age 25 (includes stepchildren). Other - Patient is the member’s grandchild, adult-sponsored dependent or of relationship not covered previously.
Block 7 Insured’s Address - Enter the complete address; street, city, state and zip code of the policyholder. If the patient’s address and the insured’s address are the same, enter “same” in this field.
Block 8 Reserved for NUCC USE - This section is reserved for NUCC use. Deleted “Patient Status” and content of field.
Block 9 Other Insured’s Name - If the patient has other health insurance, enter the name of the policyholder, name and address of the insurance company and policy number (if known).
Block 10 Is patient’s condition related to: a. Employment (current or previous)?; b. Auto Accident?; c. Other Accident?. Check appropriate block if applicable.
Block 11 Not required.
Block 11D When appropriate, enter an X in the correct box. If marked “YES”, complete 9, 9A and 9D.
Only one box can be marked.
Block 12 Patient’s or Authorized Person’s Signature - Appropriate signature in this section authorizes the release of any medical or other information necessary to process the claim. Signature or “Signature on File” and date required. “Signature on File” indicates that the signature of the patient is contained in the provider’s records.
Block 13 Insured’s or Authorized Person’s Signature - Payment for covered services is made directly to participating providers. However, you have the option of collecting for office services from members who do not have a copayment benefit and having the payments sent to
the patients. To receive payment for office services when the copayment benefit is not applicable,
Block 13 must be completed. Acceptable language is:
a. Signature in block d. Benefits assigned
b. Signature on file e. Assigned
c. On file f. Pay provider
Please Note: Assignment language in other areas of the CMS-1500 claim form or on any attachment is not recognized. If this block is left blank, payment for office services will be sent to the patient. Completion of this block is not necessary for other places of treatment.
Block 14 Date of Current - Enter the first date of illness, injury or pregnancy filed on claim- Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY) date of the first date of the present illness, injury, or pregnancy. for pregnancy, use the date of the last menstrual period (LMP) as the first date.
Block 15 Enter another date related to the patient’s condition or treatment. Enter the date in the 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY) format. Enter the applicable qualifier to identify which date is being reported.
Block 16 Dates Patient Unable to Work in Current Occupation - Enter dates, if applicable.
Block 17 Name of Referring Provider or Other Source - Enter the name ( First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim. If multiple providers are involved, enter one provider
using the following priority order:
1. Referring Provider
2. Ordering Provider
3. Supervising Provider
Do not use periods or commas. A hyphen can be used for hyphenated names. Enter the qualifier to the left of the vertical, dotted line.
Block 17A Other ID#. The non-NPI ID number of the referring physician, when listed in Block 17.
Block 17B NPI – Required. Enter the national provider identifier (NPI) for the referring physician, when listed in Block 17.
Block 18 For Services Related to Hospitalization - Enter dates of admission to and discharge from hospital.
Block 19 (Designated by NUCC) - Additional Claim information to be completed by NUCC.
Block 20 Laboratory Work Performed Outside Your Office - Enter, if applicable.
Block 21 Diagnosis or Nature of Illness or Injury- Enter the applicable ICD indicator to identify which version of ICD codes is being reported: “9” for- ICD-9-CM or “0” for ICD-10-CM codes- Note: All transactions, electronic or paper-based, for services on and after October,
1, 2015, must contain ICD-10 codes or they will be rejected. Blue Cross will not accept ICD- 9 codes with dates of services on or after October 1, 2015. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to
identify the patient’s diagnosis and/or condition. List no more than 12 ICD-9-CM or ICD-10- CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.
Block 23 Prior Authorization Number- Enter the authorization number obtained from Blue Cross/ HMO Louisiana, if applicable.
Block 24A Date(s) of Service - Enter the “from” and “to” date(s) for service(s) rendered.
Block 24B Place of Service - Enter the appropriate place of service code. Common place of service codes are:
Inpatient - 21 Outpatient - 22 Office - 11
Block 24C EMG - Enter the Type of Service code that represents the services rendered.
Block 24D Procedures, Services, or Supplies - Enter the appropriate CPT or HCPCS code. Please ensure your office is using the most current CPT and HCPCS codes and that you update your codes annually. Append modifiers to the CPT and HCPCS codes, when appropriate.
Block 24E Diagnosis Pointer - Enter the diagnosis code reference letter (pointer) as listed in Block 21 to relate the date of service and the procedures performed to the primary diagnosis.
When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. ICD-10-CM diagnosis codes must be entered in Block 21 only. Do not enter them in 24E.
Block 24F Charges - Enter the total charge for each service rendered. You should bill your usual charge to Blue Cross regardless of our allowable charges.
Block 24G Days or Units - Indicate the number of times the procedure was performed, unless the code description accounts for multiple units, or the number of visits the line item charge represents. Base units value should never be entered in the “units” field of the claim form.
Block 24J Rendering Provider ID# - Enter the national provider identifier (NPI) for the rendering physician for each procedure code listed when billing for multiple physicians’ services on the same claim. Laboratory, Durable Medical Equipment, Emergency Room Physicians,
Diagnostic Radiology Center, Laboratory and Diagnostic Services, and Urgent Care Center providers do not have to enter a physician NPI in this block. Please enter the facility NPI in blocks 32A and 33A as instructed.
*Rural health clinics and Federally Qualified Health Centers are required to enter the rendering provider NPI.
Block 24K Expand claim line to report NDC, Quanitity, and Measurement.
Block 25 Federal Tax I.D. Number - Enter the provider’s/clinic’s federal tax identification number to which payment should be reported to the Internal Revenue Service.
Block 26 Patient’s Account Number - Enter the patient account number in this field. As many as nine characters may be entered to identify records used by the provider. The patient account number will appear on the Provider Payment Register/Remittance Advice only if it
is indicated on the claim form.
Block 27 Accept Assignment - Not applicable - Used for government claims only.
Block 28 Total Charge - Total of all charges in Item F.
Block 29 Amount Paid - Not required.
Block 30 Not required.
Block 31 Signature of Provider - Provider’s signature required, including degrees and credentials.
Block 32 Name and Address of Facility - Required, if services were provided at a facility other than the physician’s office.
Block 32A NPI - Enter the NPI for the facility listed in Block 32.
Block 32B Other ID. The non-NPI number of the facility refers to the payer-assigned unique identifier of the facility.
Block 33 Billing Provider Info & Ph# - Enter complete name, address, telephone number for the billing provider.
Block 33A NPI - Enter the NPI for the billing provider listed in Block 33.
Block 33B Other ID#. The non-NPI number of the billing provider refers to the payer-assigned unique identifier of the professional.
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