CMS-1500
CMS-1450
CMS-1500 form
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This Centers for Medicare & Medicaid Services (CMS) CMS-1500 form is used for billing for prescribed medications administered in HCP offices
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It should be completed (generally electronically) and submitted to insurance provider in accordance with your organization's policies
Interact with image for a magnified view.
Field
Box 19*
Box 21
Box 23
Box 24A
Box 24D
Box 24E
Information required
Drug name, strength, dosage route, units, and NDC. A "0" should be placed in front of the NDC code to make it 11 digits
Diagnosis code (ICD-10-CM)
Prior authorization number, if available
For Medicaid, enter the N4 qualifier, NDC, NDC unit of measure and the number of NDC units (up to three decimal places) in the shaded area
CPT and HCPCS codes
Diagnosis
*Mandatory for newly approved drugs using miscellaneous J-codes.
THIS INFORMATION IS PROVIDED FOR EDUCATIONAL PURPOSES ONLY AND IS NOT A GUARANTEE OF COVERAGE. IT IS THE SOLE RESPONSIBILITY OF THE HEALTH CARE PROVIDER TO SELECT THE PROPER CODES AND ENSURE THE ACCURACY OF ALL STATEMENTS USED IN SEEKING COVERAGE AND REIMBURSEMENT FOR AN INDIVIDUAL PATIENT.
Reference: Centers for Medicare & Medicaid Services. Accessed June 23, 2020. https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1500.pdf
CMS-1450 (UB-04) form
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The CMS UB-04 form is used for billing for prescribed medications administered in hospital outpatient settings
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As with the CMS-1500 form, it should be completed and submitted to insurance provider in accordance with your organization's policies
Interact with image for a magnified view.
Field
Box 42
Box 43*
Box 44
Box 46
Box 63
Box 66
Box 80
Information required
Revenue code
Description – drug product name, strength, NDC and quantity
HCPCS code
Number of units
Treatment authorization codes
Diagnosis code (ICD-10-CM)
Miscellaneous coded drug
*Mandatory for newly approved drugs using miscellaneous J-codes.
THIS INFORMATION IS PROVIDED FOR EDUCATIONAL PURPOSES ONLY AND IS NOT A GUARANTEE OF COVERAGE. IT IS THE SOLE RESPONSIBILITY OF THE HEALTH CARE PROVIDER TO SELECT THE PROPER CODES AND ENSURE THE ACCURACY OF ALL STATEMENTS USED IN SEEKING COVERAGE AND REIMBURSEMENT FOR AN INDIVIDUAL PATIENT.
Reference: Centers for Medicare & Medicaid Services. Accessed June 23, 2020. https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-1450
CMS-1450 (UB-04) form
-
The CMS UB-04 form is used for billing for prescribed medications administered in hospital outpatient settings
-
As with the CMS-1500 form, it should be completed and submitted to insurance provider in accordance with your organization's policies
Interact with image for a magnified view.
Field
Box 42
Box 43*
Box 44
Box 46
Box 63
Box 66
Box 80
Information required
Revenue code
Description – drug product name, strength, NDC and quantity
HCPCS code
Number of units
Treatment authorization codes
Diagnosis code (ICD-10-CM)
Miscellaneous coded drug
*Mandatory for newly approved drugs using miscellaneous J-codes.
THIS INFORMATION IS PROVIDED FOR EDUCATIONAL PURPOSES ONLY AND IS NOT A GUARANTEE OF COVERAGE. IT IS THE SOLE RESPONSIBILITY OF THE HEALTH CARE PROVIDER TO SELECT THE PROPER CODES AND ENSURE THE ACCURACY OF ALL STATEMENTS USED IN SEEKING COVERAGE AND REIMBURSEMENT FOR AN INDIVIDUAL PATIENT.
Reference: Centers for Medicare & Medicaid Services. Accessed June 23, 2020. https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-1450