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Provider Manual

CMS 1500 Sample Claim Form and Instructions

Last Updated on November 26, 2018

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

To access the sample claim form, click the link below
CMS 1500 Sample Claim Form

General Information:

The Security Health Plan Processing System is designed to process standard health insurance claim forms (CMS 1500) using CPT-4 Procedure Codes or Health Care Common Procedure Coding System (HCPCS) with appropriate modifiers and ICD-10-CM Diagnosis Codes.

Refer to the following resources for guidelines on completing the CMS 1500:

Security Health Plan considers a claim complete when the following data elements are submitted (numbered as shown on the claim form). Fields in italics are required only in applicable situations.

1. Type of health insurance coverage applicable to this claim – check appropriate box
1a. Insured’s Identification Number
2. Patient’s Name
3. Patient’s Birth Date/Sex
4. Insured’s Name (“Same” or leaving blank is not acceptable.)
5. Patient’s Address
6. Patient’s Relationship to Insured
7. Insured’s Address (street, city, state, zip)
8. Not Required
9. Other Insured’s Name - If item number 11d is checked, complete 9, 9a, and 9d, otherwise leave blank
10. Check appropriate box if patient’s condition is related to:
10a. Employment
10b. Auto Accident (box 15 required)
10c. Other Accident (box 15 required)
10d. Not Required
11. Insured’s Policy Group or FECA Number
11a. Insured’s Date of Birth (MM/DD/YY) & sex
11b. Not Required
11c. Insurance Plan Name or Program Name
11d. Enter an ‘x’ in the correct box
12. Patient’s or Authorized Person’s Signature (“signature on file” is acceptable)
13. Insured’s or Authorized Person’s Signature
14. Date of current illness, injury, pregnancy (LMP)
15. Other Date – enter applicable qualifier and accident date when box 10b or 10c is checked
16. Not required
17. Name of Referring Provider or Other Source (box 17b required)
17a. Not required
17b. NPI of Referring Provider from 17
18. Hospitalization Dates Related to Current Services
19. Additional Claim Information
20. Outside lab - enter an ‘x’ in the correct box & if yes, enter the purchase price
21. Diagnosis or Nature of Illness or Injury (ICD-10-CM)
22. Resubmission Code and/or Original Reference Number
23. Prior Authorization Number
24a. Red Shaded Area: Qualifier N4 followed by the 11 digit NDC code, the quantity qualifier and the quantity.
24a. White Area: Date(s) of service (MM/DD/YY)
24b. Place of service
24c. EMG: Emergency Indicator
24d. Procedures, Services, or Supplies (CPT/HCPCS & modifier)
24e. Diagnosis Pointer
24f. Charge amount
24g. Days or Units
24h. Not required
24i. Not required
24j. Rendering Provider NPI (in the white area)
25. Federal Tax ID Number (TIN) & check appropriate box
26. Patient’s Account Number – identified and assigned by provider
27. Accept Assignment – check appropriate box if provider agrees to accept assignment
28. Total Charge – sum of all charges in 24f
29. Amount Paid – payment received from other payer or patient (do not include discounts)
30. Not required
31. Signature of Physician or Supplier Including Degrees or Credentials
32. Service Facility Location– name and address of facility where services were rendered
32a. Service Facility Location NPI– NPI for the service facility location in 32 (only report a Service Facility Location NPI when the NPI is different from the Billing Provider NPI)
32b. Not required
33. Billing Provider Information & Phone Number – name, address, and phone number of provider requesting to be paid for services rendered
33a. Billing Provider NPI – NPI of the billing provider in box 33
33b. Not required

Electronic claim submission:

Electronic Payer ID: 39045

For specific information regarding electronic claims submission, please see ‘Electronic Claims Submission’ Topic.

Paper claim submission:
Paper claims can be mailed to:
Security Health Plan
P.O. Box 8000
Marshfield, WI 54449-8000

Security Health Plan uses optical character recognition (OCR) software when processing paper claims. OCR software processes claim forms by reading text within fields on the claim form utilizing scanners to create an image. This software speeds paper claim processing if claim forms are completed correctly. Tips for submitting error-free paper claim submission:

  • Use only a CMS 1500 (02-12) red and white claim form – claim forms that are black and white may darken upon scanning resulting in certain fields to be un-readable, resulting in claim denials
  • Use black ink only
  • Required information must be filled in completely, accurately, and legibly.
  • Accurately align text within the individual fields on the claim form
  • Do not highlight data on the claim form; this shows as black on the scanned image
  • Do not staple, clip, or tape anything to the claim form
  • All attachments should be one sided; do not print double sided
  • If submitting an attachment intended for claim forms, please put a copy of the attachment behind each claim form
  • Place all necessary documentation in the envelope behind the claim form on a 8 x 11 sheet of paper; do not submit additional notes on post-its or paper size smaller than 8x11