The CMS-1500 claim form is used to submit non-institutional claims for health care services provided by physicians, other providers and suppliers to Medicare. It is also used for submitting claims to many private payers and Medicaid programs, as well as other government health insurance programs. Most institution-based services claims are submitted using a UB-04 form. Provider agreements and billing guidelines provide additional instruction for claims completion. If you wish to explore outsourcing claims and billing see factors to consider when selecting a professional billing service.
Payment of claims for MNT provided in the outpatient environment is dependent on several factors, including an individual's benefits for MNT for their condition or reason (e.g., prevention), approved settings, and the network status of the RDN (or practice) with the client/patient's payer. Claims can be submitted to payers electronically through many vehicles, including practice management systems, provider portals, and claims clearinghouses. There may be some instances where paper claims are still used.
Specific client and provider information must be provided on a CMS 1500 health insurance claim form for a payer to process a claim regardless of how it is submitted. Some payers may require additional information or require the completion of specific fields in certain situations (e.g., group number, prior authorization reference number, workers compensation). The information provided here to assist RDNs in the process of completing a claim form is general. Refer to each payer's billing instructions for more information or contact a Provider Services representative of the health plan to understand options for submitting claims.
Refer to the following sample completed claim and quick reference to assist you in completing a CMS 1500.
Some Medicare beneficiaries have secondary insurance policies (e.g., commercial insurance through work or a partner's policy) that provide benefits and coverage for conditions beyond the standard Medicare Part B MNT benefit (e.g., DM, CKD and 3 years post kidney transplant). The secondary payer may require evidence of a denied claim from the primary insurance (Medicare) before it will pay the claim (e.g., MNT for a gastroenterological or other diagnosis). A claim is submitted to Medicare that must include a modifier (GA, GZ or GY) to generate a denial required before the secondary insurance will review the claim. For more information, including descriptions and use of each modifier, refer to the RDNs Complete Guide to Credentialing and Billing: The Private Payer Market or to page 8 of the CMS Manual.
When completing claims electronically (e.g., use of a clearinghouse) you will also select a payer ID, a unique code for each payer. Some payers may require providers to complete an agreement before they will accept electronic claims through a third-party service such as a claims clearinghouse. Otherwise, claims clearinghouses allow you to select participating payers from a menu.
Medicare electronic claims transactions must meet Electronic Data Interchange requirements. RDN Medicare providers can submit claims using applications that meet Medicare's EDI requirements. Providers must complete an EDI enrollment agreement. Registered dietitian nutritionists are able to submit claims electronically to a Medicare Administrative Contractor (MAC). Registered dietitian nutritionists should contact their MACs for more information.
For more comprehensive instructions regarding claims submission, refer to the RDNs Complete Guide to Credentialing and Billing: The Private Payer Market.
The form specifications require red drop out ink in order to facilitate the use of image processing technology such as Image Character Recognition (ICR), facsimile transmission and image storage. It is available in various formats (e.g., single copy, duplicate, etc.). The CMS-1500 claim form may be purchased from local printers, office supply stores, or through the U.S. Government Printing Office: