What is box 11 in CMS 1500?

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Box 11 on the CMS-1500 Claim Form is designated for the Insured’s Policy, Group, or FECA Number (the primary policy or group number of the person carrying the insurance).

Breakdown of Box 11 and Sub-Fields

  • Box 11: Enter the primary insured's policy number, group number, or Federal Employees' Compensation Act (FECA) number as shown on their insurance card. Do not leave it blank, even if there is only one insurance plan, to avoid coordination of benefits (COB) rejections.
  • Box 11a: Records the insured's date of birth (MM/DD/YYYY) and sex (gender)—use the insured's information, not the patient's, if the patient is a dependent.
  • Box 11b: Lists the employer's name or school name, if applicable to the policy.
  • Box 11c: Enters the full name of the insurance plan or program (e.g., Medicare, Aetna, BCBS).
  • Box 11d: Marks whether there is another health benefit plan ("YES" or "NO"). If marked "YES," you must also fill out Unified Practice CMS-1500 Cheat Sheet Boxes 9, 9a, and 9d for secondary insurance details.

Which is entered in block 11c of the CMS 1500?

The name of the policyholder's commercial health insurance plan or program is entered in Block 11c of the CMS-1500 claim form.

Key Details for Block 11c

  • Content: Enter the complete primary insurance plan name, program name, or the nine-digit payer ID number if required by the specific payer.
  • Context: This field works alongside other fields in Section 11, where Block 11 captures the group number and Block 11a captures the policyholder's birth date and gender.

What information goes into block 11 of a CMS claim form?

Block 11 of the CMS-1500 claim form requires the insured's policy number, group number, or FECA (Federal Employees' Compensation Act) number for the primary insurance.

Key Requirements for Block 11

  • Primary Insurance: Enter the policy or group number of the primary health plan that is primary to Medicare or the current payer.
  • No Other Insurance: If there is no primary or secondary insurance other than the main payer, enter the word "NONE" instead of leaving it blank. Leaving it blank can result in claim rejections due to coordination of benefits (COB) issues.
  • FECA Claims: For federal workers' compensation work-related conditions, enter the FECA number.

Related Sub-Blocks (11a–11d)

  • Block 11a: Insured's date of birth (in an 8-digit MMDDYYYY format) and sex/gender.
  • Block 11b: Other claim ID or employer/school name (often left blank or used for specific secondary identifiers depending on the payer guidelines).
  • Block 11c: Insurance plan name or program name of the primary insurance.
  • Block 11d: Indicator asking if there is another health benefit plan (marked Yes or No).

What are the boxes in CMS 1500?

The CMS-1500 claim form contains 33 numbered fields (boxes) used by healthcare providers to bill insurance companies for professional services.

The boxes are organized into four main sections from top to bottom:

Patient and Insurance Information (Boxes 1–13)

  • Boxes 1–1a: Type of health insurance coverage (Medicare, Medicaid, Group Health Plan) and the insured’s identification number.
  • Boxes 2–3: Patient's full legal name, date of birth, and gender.
  • Boxes 4–7: Insured's name, patient address, relationship to the insured, and insured's address.
  • Box 8: Reserved for National Uniform Claim Committee (NUCC) use (left blank).
  • Boxes 9–9d: Information for secondary or other insurance policies.
  • Boxes 10a–10d: Indications of whether the patient's condition is related to employment, auto accidents, or other accidents.
  • Box 11: Primary policy or group number.
  • Boxes 12–13: Patient and insured signatures (or "signature on file") authorizing the release of medical information and assignment of benefits.

Condition and Clinical Context (Boxes 14–23)

  • Boxes 14–15: Dates of current illness, injury, or pregnancy, along with required qualifiers.
  • Box 16: Dates the patient was unable to work.
  • Boxes 17–17b: Name of the referring or ordering provider and their National Provider Identifier (NPI).
  • Box 18: Related hospitalization dates.
  • Box 19: Additional local use or extra processing information.
  • Box 20: Outside lab charges and indicators.
  • Box 21: Up to 12 ICD-10-CM diagnosis codes (labeled A through L).
  • Box 22: Resubmission code and original reference number.
  • Box 23: Prior authorization or referral number.

Service Details (Boxes 24A–24J)

This middle grid contains rows for individual service lines, detailing dates of service, place of service codes, CPT/HCPCS procedure codes, modifiers, diagnosis pointers (linking to Box 21), charges, units, and the rendering provider's NPI.

Provider and Billing Information (Boxes 25–33)

  • Box 25: Provider or organization Federal Tax ID (EIN or SSN).
  • Box 26: Patient account number.
  • Box 27: Acceptance of assignment checkmark.
  • Box 28: Total charges for the claim.
  • Box 29: Amount paid by another payer.
  • Box 30: Reserved for NUCC use.
  • Box 31: Physician or supplier signature and date.
  • Box 32–32b: Service facility location name, address, and NPI (where services were performed).
  • Box 33–33b: Billing provider's name, address, phone number, and group NPI (who is getting paid).

How to fill out a CMS 1500 claim form?

You can review detailed field definitions and requirements using the CGS Medicare CMS 1500 Form Tutorial or read the official guidelines provided by the National Uniform Claim Committee.

The CMS-1500 claim form is the standard paper claim form used by professional healthcare providers and suppliers to bill insurance payers. It contains 33 distinct blocks split into patient/insured demographics and clinical/provider details.

Key Sections and Instructions

Section 1: Patient and Insured Information (Boxes 1–13)

  • Box 1 & 1a: Select the correct insurance type (Medicare, Medicaid, Group Health, etc.) and enter the insured's unique ID number.
  • Box 2–5: Provide the patient's full name (Last, First, M.I.), birth date (MM/DD/YYYY format using an 8-digit structure), sex, and physical mailing address.
  • Box 6: Check the patient's relationship to the insured (Self, Spouse, Child, Other).
  • Box 12 & 13: Enter "Signature on File" (SOF) or secure required signatures/dates authorizing the release of medical data and assignment of benefits.

Section 2: Condition and Treatment Details (Boxes 14–23)

  • Box 14 & 15: Enter the date of current illness, injury, or pregnancy alongside the appropriate qualifier code.
  • Box 17: Record the name and National Provider Identifier (NPI) in Box 17b of the referring or supervising provider.
  • Box 21: Enter the diagnosis codes (using ICD-10 indicators, usually designated with a 0).
  • Box 24 (A–J): Detail each specific line item service, including service dates, place of service code (e.g., 11 for office), CPT/HCPCS procedure codes, charges, units, and the rendering provider's NPI.

Section 3: Billing Provider Information (Boxes 24–33)

  • Box 25 & 28: Input the provider or organization's Federal Tax ID (EIN or SSN) and record the total charges for all listed lines.
  • Box 31 & 33: Provide the physician's or supplier's signature/date, and fill out the complete billing provider name, address, phone number, and NPI in Box 33.

General Formatting Rules

  • No Special Characters: Avoid dollar signs ($), commas (,), or decimal points (.) in monetary boxes unless specifically requested by your electronic/clearinghouse formatting guidelines.
  • Clean Forms: Never staple, tape, or paste stickers onto a physical paper claim form, as it disrupts automated optical character recognition scanning.

CMS 1500 claim form Box 11, Insured’s Policy, Group, or FECA Number, Description/Details/Explanation

9 related questions found

What will cause a CMS-1500 claim to be rejected?

A CMS-1500 claim is typically rejected before processing due to missing, invalid, or inaccurate data fields.

Common Causes of CMS-1500 Rejections

  • Incorrect Patient or Insured Information: Mismatches or typos in the patient's name, date of birth (Box 3), or member/policy ID number (Box 1a) cause immediate front-end rejections.
  • Provider Identifier Errors: Leaving the National Provider Identifier (NPI) blank or entering an incorrect NPI for the rendering provider (Box 24J) or billing provider (Box 33a) halts the claim.
  • Invalid or Deleted Diagnosis Codes: Using an inactive, deleted, or insufficiently specific ICD-10 code in Box 21 violates medical necessity guidelines and results in an automatic rejection.
  • Missing Tax ID or Employer ID: Failing to include or mistyping the federal Tax ID or SSN in Box 25 triggers entity code rejections.
  • Missing Referring Provider Details: Leaving Box 17 blank when services or therapies require a referral or order from an attending or consulting doctor will stop the claim.
  • Incorrect Payer ID: Submitting the form using the wrong electronic payer ID prevents the clearinghouse or insurance carrier from routing the claim correctly.

In which block of CMS-1500 will get prior authorization?

Block 23 is used for the prior authorization number on a CMS-1500 claim form.

Key Details for Block 23

  • Field Name: Prior Authorization Number or Quality Improvement Organization (QIO) certification number.
  • Usage: Enter the specific prior authorization, referral number, or unique tracking number (UTN) provided by the insurance payer when required for specific medical services or procedures.
  • Formatting: Up to 30 alphanumeric characters can typically be entered depending on payer rules.

Which information is entered in the CMS-1500 block?

The CMS-1500 Claim Form requires specific patient, insurance, and provider data across its 33 numbered blocks.

Key CMS-1500 Blocks and Their Information

  • Block 1 & 1a: Type of health insurance coverage (Medicare, Medicaid, Private) and the insured's ID number.
  • Block 2: Patient's full name (last, first, middle initial).
  • Block 3: Patient's birth date (MM/DD/YYYY) and sex.
  • Block 4: Insured's name (if different from the patient).
  • Block 5: Patient's address and telephone number.
  • Block 9–9d: Other insured's name, policy/group number, and supplemental plan information (if secondary insurance exists).
  • Block 14: Date of current illness, injury, or pregnancy (LMP).
  • Block 17: Name of the referring provider or other source.
  • Block 21: Diagnosis codes (up to 12 ICD-10 codes) explaining medical necessity.
  • Block 24A–24J: Details of specific services, including dates of service, CPT/HCPCS procedure codes, charges, days/units, and rendering provider NPI.
  • Block 25: Federal Tax ID number (EIN) or Social Security Number (SSN) of the provider/supplier.
  • Block 31: Provider signature and date.
  • Block 33: Billing provider's name, address, phone number, and NPI.

What are the most common errors or mistakes made when filling out the CMS-1500 claim form and how can these be avoided?

The most common errors on the CMS-1500 Claim Form involve incorrect patient demographics, inaccurate or unspecific medical codes, and missing provider identification data.

Top Mistakes and How to Avoid Them

  • Incorrect Patient Demographics & Insurance Info (Boxes 1–13): Spelling the patient's name wrong, mismatching the birth date, or using an old member ID number causes instant rejections.
    • How to avoid: Verify insurance eligibility electronically before every visit and ask patients to update their personal information at least twice a year.
  • Using Unspecific or Invalid ICD-10 Diagnosis Codes (Box 21): Submitting general codes instead of coding to the highest level of specificity—or omitting the correct diagnosis pointer in Box 24E—leads to denials for lack of medical necessity.
    • How to avoid: Check current codebooks to ensure you select the most specific code available for the patient's exact condition.
  • CPT/HCPCS and Modifier Errors (Boxes 24D & 24ID): Using outdated procedure codes, mismatched modifiers, or failing to include place-of-service (POS) codes triggers billing flags.
    • How to avoid: Read full code descriptions rather than short text, and double-check required telehealth or service-specific modifiers before submitting.
  • Missing or Mismatched Provider NPI and Tax ID (Boxes 24J & 33): Mixing up the rendering provider NPI with the billing provider NPI, or having a taxonomy code mismatch, stops claims during adjudication.
    • How to avoid: Maintain a clean provider database and ensure your National Provider Identifier (NPI) and taxonomy codes match active enrollment records.
  • Omitted Prior Authorizations (Box 23): Forgetting to enter the prior authorization or referral number results in automatic service denials.
    • How to avoid: Implement a pre-submission checklist to verify that authorization numbers are attached to every service line that requires them.
  • Using Outdated Form Versions or Bad Formatting: Submitting an old version of the paper form, using wrong ink colors, or misaligning text can break optical character recognition (OCR) scanners.
    • How to avoid: Transition to electronic claims submission (837P) whenever possible, or use certified billing software that prints correctly aligned data on the current 02/12 form version.

Can you fill out CMS-1500 by hand?

You should not fill out the CMS 1500 form by hand.

Why Handwriting Is Not Allowed

  • Scanner Rejections: Insurance companies use Optical Character Recognition (OCR) machines to read claims. These scanners cannot read messy or handwritten text well.
  • Processing Delays: Handwritten forms often cause errors. This leads to claim denials or slow payments.
  • Payer Rules: Most insurance payers and Medicare require typed, computer-printed, or electronic submissions (837P formats).

Best Practices for Paper Submissions

  • Use a Printer: Print forms using a laser or inkjet printer with true black ink.
  • Use Correct Fonts: Type in all uppercase letters using standard fonts like Courier New or Times New Roman.
  • Use Original Paper: Always print on the official red-and-white CMS 1500 (02/12) scannable form. Photocopies or black-and-white copies are rejected.