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Here is Tricare for CMS 1500

Here is Tricare for CMS 1500. Follow the POWER POINT to help complete the CMS-1500 form for tricare. Then complete the other 3 on your own. Good luck –Mrs. Fogle . Claims Instructions Blocks 1–3. Block 1: Enter X in CHAMPUS box Block 1a: Enter sponsor’s SSN

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Here is Tricare for CMS 1500

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  1. Here is Tricare for CMS 1500 Follow the POWER POINT to help complete the CMS-1500 form for tricare. Then complete the other 3 on your own. Good luck –Mrs. Fogle 

  2. Claims InstructionsBlocks 1–3 • Block 1:Enter X in CHAMPUS box • Block 1a:Enter sponsor’s SSN • Block 2:Enter patient’s complete name as it appears on the ID card • Block 3:Enter patient’s DOB as MM DD YYYY (with spaces) and X in appropriate box to indicate gender

  3. Claims InstructionsBlocks 4–6 • Block 4:Enter sponsor’s complete name; enter SAME if the sponsor is the patient • Block 5:Enter patient’s mailing address, zip code, area code, and telephone number • Do not enter APO or FPO addresses • Block 6:Enter X in the appropriate box to indicate patient’s relationship to sponsor

  4. Claims InstructionsBlocks 7–9 • Block 7:Enter sponsor’s mailing address; enter SAME if sponsor is the patient • Block 8:Enter X in appropriate box to indicate marital, employment, and/or student status • Blocks 9–9d:Leave blank

  5. Claims Instructions Blocks 10–12 • Blocks 10a–c:Enter X in the appropriate boxes • Block 10d:Leave blank • Blocks 11–11c:Leave blank • Block 11d:Enter an X in the appropriate box • Block 12:Enter SIGNATURE ON FILE; leave date blank

  6. Claims InstructionsBlocks 13–14 • Block 13:Enter SIGNATURE ON FILE; leave date blank • Block 14:Enter date as MM DD YYYY (with spaces) to indicate date patient first experienced signs/symptoms of illness/injury; enter date of LMP for obstetric visits

  7. Claims InstructionsBlocks 15–16 • Block 15:Enter date as MM DD YYYY (with spaces) to indicate first date patient had same or similar illness/injury, if documented • Block 16:Leave blank

  8. Claims InstructionsBlock 17 • Block 17:Enter complete name and credentials of referring provider • If patient was referred by MTF, enter name of facility and attach DD Form 261 or SF 513 • Block 17a:Enter referring physician’s EIN or SSN

  9. Claims InstructionsBlocks 18–20 • Block 18:Enter admission and discharge dates as MM DD YYYY (with spaces) if patient was inpatient; if still inpatient, leave TO box blank • Block 19:Leave blank • Block 20:Enter X in NO box

  10. Claims InstructionsBlocks 21–23 • Block 21:Enter ICD code number for diagnosis or conditions treated • Block 22:Leave blank • Block 23:Enter prior authorization number or authorization number, if applicable

  11. Claims InstructionsBlocks 24A–24D • Block 24A:Enter date procedure was performed in FROM box as MMDDYYYY; enter date in TO box if procedure/service was performed on consecutive days • Block 24B:Enter POS code • Block 24C:Leave blank • Block 24D:Enter CPT/HCPCS code(s) and modifier(s)

  12. Claims InstructionsBlocks 24E–24K • Block 24E:Enter diagnosis reference number (1–4) for the ICD code reported in Block 21 • Block 24F:Enter fee charged to patient’s account for procedure/service performed • Block 24G:Enter number of units/days • Blocks 24H-K:Leave blank

  13. Claims InstructionsBlocks 25–30 • Block 25:Enter billing entity’s EIN or SSN and enter X in appropriate box • Block 26:Enter patient account number • Block 27:Enter X in YES box • Block 28:Enter total charges • Block 29:Leave blank • Block 30: Enter balance due

  14. Claims Instructions Blocks 31–32 • Block 31:Enter signature of provider or his/her representative; enter date as MMDDYYYY (without spaces) • TRICARE requires provider’s actual signature or use of signature stamp on printed claim • Block 32: Enter name and address of MTF that provided services

  15. Claims Instructions Block 33 • Block 33: Enter provider’s telephone number with area code, official name of billing entity, and mailing address; leave PIN and group numbers blank

  16. Modifications to Claims with Supplemental Coverage • Block 9:Enter complete name of supplemental policyholder if different from patient; otherwise enter SAME • Block 9a:Enter ID and group number of supplemental policy • Block 9b:Enter supplemental policyholder’s DOB as MM DD YYYY; enter X in appropriate box for gender

  17. Modifications to Claims with Supplemental Coverage • Block 9c:Enter name of supplemental policyholder’s employer • Block 9d:Enter name of supplemental plan • Block 10d:Enter the word ATTACHMENT • Attach remittance advice from supplemental plan to CMS-1500 • Block 11d:Enter X in YES box

  18. Claims Modifications When TRICARE Is Secondary • Block 11:Enter ID number of health insurance plan primary to TRICARE • If Medicare, enter MEDICARE after number • Block 11a:If policyholder is not patient, enter primary policyholder’s DOB as MM DD YYYY; enter X in appropriate box to indicate gender (otherwise leave blank)

  19. Claims Modifications When TRICARE Is Secondary • Block 11b:Enter name of primary policyholder's employer • Block 11c:Enter name of primary insurance plan • Block 11d:Enter X in YES box

  20. Claims Modifications When TRICARE Is Secondary • Block 29:Enter reimbursement received from primary insurance plan • Attach remittance advice received from primary plan to the CMS-1500 claim

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