Professional billing on the CMS-1500
Your claim for professional services must be submitted on a standard CMS-1500 form (02-12 version or later).
Also see: Mid-level provider coding and reimbursement.
- We prefer to receive claims electronically (learn how to set up electronic data interchange), but you can also mail them to our claims addresses.
- Hand-written or faxed claims will not be accepted.
- Do not use red ink, highlighters, neon stickers, labels or rubber stamps.
- Fill out an original claim form in its entirety. Do not use copies of claim forms.
- Print claim data within the boxes.
- Do not put notes at the top or bottom of the claim.
- Use a laser printer.
- Do not print slashed zeros.
Required CMS-1500 field information
Item 1: Indicate all types of insurance coverage applicable
Item 1a: Contract number plus two-digit suffix. For Medicaid use the patient's recipient's ID number
Item 2: Patient's name
Item 3: Patient's date of birth and gender
Item 4: Insured's name
Item 5: Patient's address
Item 6: Patient's relationship to the insured
Item 7: Insured's address
Item 9a & 9d: Other insurance information
Item 10: Patient's condition related to:
Item 10a-c: Employment, auto or other accident
Item 11: Insured's group number
Item 12: Patient's signature on file
Item 13: Insured's signature on file
Item 14: Date of current illness, injury or pregnancy
Item 15: Indicate if patient has had same or similar illness; other date
Item 17: Qualifier and name of referring physician
Item 17b: NPI of referring physician; required except if patient is self-referring
Item 18: Hospitalization dates related to current service, if applicable
Item 19: Additional claim information; use for prenatal dates of service, description of unlisted codes, or reason for corrected claim
Item 21: Diagnosis using standard ICD-10 CM diagnosis code; use primary diagnosis code and indicator first
Item 22: Corrected claim code, if applicable: See Making corrections for use
Item 23: Prior authorization number, if applicable
Item 24a: Date the service was provided
Item 24b: Place of service - Priority Health will accept all standard Medicare place of service codes
Item 24d: CPT and/or HCPCS codes, modifiers when necessary; for unlisted procedure codes, specify what service is being provided.
Item 24e: Link service to any diagnosis listed in Item 21, as applicable
Item 24f: Charges
Item 24g: Days or units
Item 24i: ID qualifier, for taxonomy codes
Item 24j: Rendering provider NPI
Item 25: Federal tax ID number
Item 26: Patient's account number
Item 27: Accept assignment
Item 28: Total charges
Item 31: Typed first name then last name of physician or supplier, including degrees or credentials (no handwritten signatures accepted)
Item 32: Name and address of facility where services were rendered
Item 32a: NPI of service facility
Item 32b: Taxonomy codes
Item 33: Physician's or supplier's billing name and address (Social Security number or owner of tax ID number)
Item 33a: NPI of billing provider
Item 33b: Taxonomy codes
Check for edits before you bill
Our online Edits Checker tool lets you enter professional or facility claim data and view any clinical edits that will apply, with the associated rationale.
Submitting electronic claims
Mailing paper claims
Priority Health Claims
P.O. Box 232
Grand Rapids, MI 49501
- Status claims
- Claims Inquiry tool guide
- Edits Checker tool guide
- Claim deadlines
- Set up electronic payments
- BH provider billing
- Facility billing
- Advanced practice professional billing
- Professional billing
More billing topics:
- ACA non-payment grace period
- Ambulatory surgery center billing
- Balance billing
- Clinical edits
- Check reissue procedure
- COB: Coordination of benefits
- Correcting claims
- Correcting overpayments & underpayments
- Diagnosis coding
- Dual-eligible members
- Front-end rejections
- Gender-specific services
- Medicaid billing
- NDC numbers on drug claims
- Office-based procedures billing
- Risk adjustment
- Unlisted codes, drugs & supplies