CMS Claim Instructions: A Step by Step Guide

Woman with map pointing at the words "CMS Claim Form Instructions" implying that she knows the way to fill out a health insurance claim form

Filling out a claim form is largely done online through the use of electronic health record systems. However, the knowledge of how a claim form is filled out is fundamental in order to troubleshoot a wide range of issues that may arise in the course of mental health billing. If you know how a claim form works and how one should be filled out it will help save you valuable time if you run into an issue.

In this blog, we will look at an actual claim form and take you step-by-step through the process of filling it out, including helpful tips along the way to help troubleshoot common billing errors. The claim form that we used can be found on Cigna’s website, and is representative of what most claim forms look like.

The Header of the Claim Form

This is the header of the claim form. You can see at the far right of the form there is the word “Carrier”. This means that you are supposed to put the name and address of the insurance carrier for your client in this section. This could be any one from a wide range of insurance companies such as Cigna, Aetna, BCBS, or any other insurance company that is going to pay for services. Verify with your client which insurance they have to know what information to include in this box.

Tip: It is important to get the address of the insurance carrier perfect in this box. You can’t just look up the address of the insurance company online and insert whatever address comes up. Sometimes the claims address is on the back of the client’s insurance card and sometimes it is in the provider manual. It is important to know that address ahead of time so that your claim is not rejected by the insurance company.

Patient and Insured Information

The section of a health insurance claim form where information of the patient and the insured is input

This is where the meat of the demographic information for your client and their insurance information is input. Each section is delineated with the box numbers up above. Below we will outline what each box number is and what information should be included.

Box 1: This is where you would designate what kind of insurance the client has. For private insurance, you would likely select Group Health Plan but in some cases, you would select another.

Tip: Our team knows how to set this up in your electronic health record so that it is automated. If you are consistently getting claim rejections this is the first place that you would want to look to make sure that the settings are updated correctly.

Box 1a: This is where the insured’s ID number goes. It is important that the number in this box is the exact right number listed on the insurance card for the client. If this is not the exact number listed on the insurance card then the claim will reject. For example, If you switch two numbers or miss a number, then the claim will not be able to be processed and result in a rejection. It is very important for cash flow that this number is the exact number on the insurance ID card.

Box 2: This is where the patient’s name goes. It is important to note the format; Last Name, First Name, Middle Initial. This is the precise format that the name needs to be in for the claim to process correctly. Keep in mind that the name must be the same as the name listed on the insurance card.

Tip: Sometimes names are misspelled or incorrectly entered when a client registers for insurance. If the name is misprinted on the insurance card then that is the name that needs to be on the insurance claim until the name on the insurance card can be fixed. It is critical that the name on the insurance card is the exact same name on the claim form.

Box 3: This is where the patient’s date of birth and sex is listed. The format of the birthday is MM/DD/YY. The date of birth must be the same date listed on the eligibility and benefits check that you did on the client otherwise the claim will not pay. The sex must be male or female and must be an identical match to what is listed on the insurance enrollment paperwork. We understand there is a lot of nuance around this topic and some of our clients specialize in gender/sex-based work, but in order for the claim to process accurately the information on the claim must match what the insurance company has on file.

Box 4: This is where the insured’s name goes. If the patient is the insured party, then the name would be exactly the same. If the insured is a different person than the patient, then this is where the insured’s name would be. Again the format is the same; Last Name, First Name, Middle Initial.

Box 5: This is where the patient’s address is inputted into the system. The address must match what the insurance company has in the system regardless of where the client is staying. Some clients move houses or split their time between living situations, but for the sake of the claim processing correctly the address must be the same as the address on the enrollment paperwork which you can find by doing an eligibility and benefits check.

Box 6: This is where the patient’s relationship with the insured is placed. The options that you have are self, spouse, child, or other. That should cover the range of options and your job is to put the option that best matches the relationship with the insured.

Box 7: Indicate the client’s address if they are the insured, which may be a duplicate of Box 5. If the insurance is through someone else such as a parent or spouse (the “insured”), write down their address and phone number, which may be different from Box 5

Box 8: Leave blank.

Box 9: This is only used if the client has multiple insurances (typically a primary and secondary). This could be a whole other blog post, so billing multiple insurances will not be covered here.

Box 10: The answers to these questions are all typically “no.”

Box 11: Enter the Insurance group # (found on the insurance ID card).

Box 11a: Enter the client’s date of birth (abbreviated DOB), or if the insurance is through someone else, enter their birthdate.

Box 11b-c: Leave blank.

Box 11d: If they only have one insurance check “no.” If they have two insurances check “yes” (and see Box 9).

Box 12 and 13: “Signature on file” and date of first visit is sufficient.

Physician or Supplier Information

Boxes 14-20: Leave blank.

Box 21: Enter diagnosis code(s) according to DSM 5 requirements.

Box 22: Only needs to be filled out if you are re-submitting a claim. The code is “7” and the “original reference no.” is the one the insurance company assigned on the EOB.

Box 23: Typically is left blank, unless you had to get an authorization.

Box 24a: Date of service (same in both boxes)

Box 24b: Place of service, typically will be “office” which is code “11.”

Box 24c: Leave blank

Box 24d: CPT code for what type of session you did. “Modifier” is only entered in certain circumstances, for example, “HJ” on the claim pictured indicates it was an EAP session.

Box 24e: Diagnosis pointer means which diagnosis was addressed/worked on in the session (in this case there is only one so “A” is indicated).

Box 24f: The amount you charged (your full fee, otherwise known as your standard rate).

Box 24g: Units – in this case 1 since you did one session.

Box 24h: Leave blank.

Box 24i: NPI.

Box 24j: Enter your NPI#. This would be your Type 1 NPI

Box 25: Enter your Tax ID# or SS#. You have to, however, set it up with the insurance company. When you credentialed with the insurance company, you choose which identifier you want them to have on file. Most practices determine to use their tax ID number.

Box 26: Patient’s Account #. This is a # you assign to the patient, it can be whatever you want it to be. You can also leave this box blank in case you don’t have a patient account number. Some practices have numbering conventions for their client files and some don’t.

Box 27: Check “yes” if you want the insurance payment sent to you directly. If you want the payment sent to the client check “no”.

Box 28: Your total charge (full fee).

Box 29: Amount client paid. For example, the co-payment you collected at the time of the session.

Box 30: Leave blank.

Box 31: Your signature and credentials (can be typed) and dated.

Box 32: Your office name and address. This is going to depend on which name and address the insurance company has on file. This could differ depending on who did the credentialing or if you are a telehealth practice, you will need to make sure you have the correct address and name on file.

Box 32a: Your NPI# (either group or individual depending on how you are contracted with the insurance company). If you are unsure of your individual NPI or your group NPI you can find it on the national NPI registry. To confirm how you are contracted, you will need to reference your contract or contact the insurance company.

Box 33: Your name and address or the name of your group and address of the office (again depending on how you are contracted with the insurance company depends on what you would put in).

Box 33a: Either the group or individual NPI#. If you are unsure of your individual NPI or your group NPI you can find it on the national NPI registry. To confirm how you are contracted, you will need to reference your contract or contact the insurance company.

Have further questions? Feel free to reach out to our team!