CMS 1500 Items 1-7: Patient and Insured Information

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Introduction

From electronic options to paper forms, the CMS-1500 remains a common claims format. This guide clarifies the often-confusing first seven items: patient and insured information like names, addresses, and IDs. Whether submitting electronically or on paper, you’ll find precise instructions for accurate completion. Let’s understand how to fill CMS 1500 items 1-7.

Details of CMS 1500 Items 1-7

Item 1: Medicare, Medicaid, Tricare, CHAMPVA, Group Healthcare Plan, FECA, Other

‘Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA (Federal Employee Compensation Act), Black Lung, Other’ means the insurance type to which the claim is being submitted. ‘Other’ indicates health insurance including HMOs, commercial insurance, automobile accident, liability, or workers’ compensation. This information directs the claim to the correct program and may establish primary liability. Indicate the type of health insurance coverage applicable to this claim by placing an X in the appropriate box. Only one box can be marked.

Item 1A: Insured’s ID Number

Enter the insured’s ID number as shown on the insured’s ID card for the payer to which the claim is being submitted. If the patient has a unique Member Identification Number assigned by the payer, then enter that number in this field.

For TriCare: Enter the DoD Benefits Number (DBN 11-digit number) from the back of the ID card.
For Workers Compensation: Enter the appropriate identifier of the employee.
For Other Property and Casualty Claims: Enter the appropriate identifier of the insured person or entity.

Item 2: Patient’s Name

Enter the patient’s full last name, first name, and middle initial. If the patient uses a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name. The ‘Patient’s Name’ is the name of the person who received the treatment or supplies. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name. Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.

Item 3: Patient’s Birth Date, Sex

Enter the patient’s 8-digit date of birth (MM | DD | YYYY). Enter an X in the correct box to indicate the sex (gender) of the patient. Only one box can be marked. If sex is unknown, leave it blank. The ‘Patient’s Date of Birth, Sex’ is information that will identify the patient and it distinguishes persons with similar names.

Item 4: Insured’s Name

The ‘Insured’s Name’ identifies the person who holds the policy, which would be the employee for employer-provided health insurance. This field applies to claims ‘submitted for a dependent enrolled under the insured’s policy.’ Enter the insured’s full last name, first name, and middle initial. If the insured uses a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name. Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.

For Workers Compensation: Enter the name of the Employer
For Other Property and Casualty Claims: Enter the name of the insured person or entity

Item 5: Patient’s Address (Multiple Fields)

Enter the patient’s address. The first line is for the street address; the second line is the city and state; the third line is the ZIP code. Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Report a 5 or 9-digit ZIP code. Enter the 9-digit ZIP code without the hyphen. The ‘Patient’s Address’ is the patient’s permanent residence. A temporary address or school address should not be used.

Item 6: Patient Relationship to Insured

Enter an X in the correct box to indicate the patient’s relationship to the insured when Item Number 4 is completed. Only one box can be marked. The ‘Patient Relationship to Insured indicates how the patient is related to the insured. ‘Self’ would indicate that the insured is the patient. ‘Spouse’ would indicate that the patient is the husband or wife or qualified partner, as defined by the insured’s plan. ‘Child’ would indicate that the patient is the minor dependent, as defined by the insured’s plan. ‘Other’ would indicate that the patient is other than the self, spouse, or child, which may include employee, ward, or dependent, as defined by the insured’s plan.

Item 7: Insured’s Address

Enter the insured’s address. If Item Number 4 is completed, then this field should be completed. The ‘Insured’s Address’ is the insured’s permanent residence, which may be different from the patient’s address in Item 5. The first line is for the street address; the second line is the city and state; the third line is the ZIP code. Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Report a 5 or 9-digit ZIP code. Enter the 9-digit ZIP code without the hyphen.

For Workers Compensation: Enter the address of the Employer. Do not use a hyphen or space as a separator within the telephone number.
For Other Property and Casualty Claims: Enter the address of the insured noted in Item 4. Do not use a hyphen or space as a separator within the telephone number.

We hope that you got a clear idea of how to fill CMS 1500 items 1-7. The CMS-1500 form is tough to master and it’s just one piece of a big thousand-piece billing puzzle! Don’t worry, contact PrimeCare and forget about your billing worries. We are a trusted medical billing service provider for solo practitioners and small group practices. With our assistance, you can simply focus on your patients and you don’t have to worry about insurance reimbursements. We will handle it for you, ’cause that’s what we are good at. See you soon.

Reference:

Additional CMS 1500 Resources

CMS 1500 Items 1-7: Patient and Insured Information