CMS 1500 Overview
  • 08 Feb 2024
  • 4 Minutes to read
  • Dark
    Light
  • PDF

CMS 1500 Overview

  • Dark
    Light
  • PDF

Article Summary

When billing third party payors, you might be required to use a form called the CMS1500 or the electronic version called the 837p. 

  • Managed by the National Uniform Claim Committee, the CMS1500 is the standard health insurance claim form used by a non-institutional provider or supplier to bill Medicaid State Agencies, Medicare carriers, insurance companies, and durable medical equipment regional carriers. The electronic forms use X12 standards.
  • Please contact your payor for further information.
  • For detailed instructions on the CMS1500, please review www.nucc.org
  • You can also submit claims through a clearinghouse. We do not recommend one clearinghouse over the other. We've heard of Trizetto, Availity, ClaimMD, Waystar, Change Healthcare, and others.  You could also search for clearinghouse, claims management, or EDI clearinghouses.

The "Puzzle" In Generations

Several areas of Generations are used to create a CMS1500/837p. Because you don't see a completed CMS1500 until all areas are completed, we sometimes describe the form as a jigsaw puzzle. Your job is to determine the requirements for your payor and place data in appropriate fields of Generations. The pieces of the puzzle in Generations are:

  • CMS1500 Billing Defaults in Company Settings.
  • Service Code Master List.
  • Payor Master List
  • CMS1500 Billing Form for each individual Client.
  • (Optional) If you are required to keep track of the hours or dollars you are allowed, you may want to consider using Service Orders to assist with keeping within limitations.

While the CMS1500 is a complicated form, we've broken it down into small pieces. Take your time in completing the puzzle, and you'll be billing with the CMS1500 in no time!

Help Articles

  • Step-by-Step: a detailed look at completing the puzzle pieces.
  • Line-by-Line: a breakdown of all lines on the CMS1500/837p.

Videos

Watch an overview about the CMS1500 and 837p


Watch a video about notable fields in the CMS1500/837p.

Watch a video about generating the CMS1500/837p

Electronic Billing

For electronic submission of the CMS1500, Generations provides the 837p and/or a Print Image file that generates a .TXT file in ANSI 5010 format. Electronic billing is sometimes called EDI. EDI is an abbreviation for Electronic Data Interchange and refers to the 837p (or 837i for the electronic version of the UB04.)

  • We recommend that files are sent to a clearinghouse to easily identify and correct any rejections.  We do not recommend one clearinghouse over the other. We've heard of Trizetto, Availity, ClaimMD, Waystar, Change Healthcare, and others.  You could also search for clearinghouse, claims management, or EDI clearinghouses.
  • Indiana: In some cases a provider can submit the 837p directly to the State and bypass using a clearinghouse. Contact Indiana Medicaid for more information.
  • New York: The Billing Export is accepted by Buffalo Intelligent Technology Systems (BITS.)
  • You may be able to bill a Payor directly; however, you must ensure that the Payor provides you with a rejection report so you can understand items that need to be fixed. You will probably also send several test files to the payor before sending production files.
  • Generations produces output of both the 837p and 837i for electronic billing. While the majority of payor requirements are met by the built in configuration options provided by Generations, some payors may have unique requirements that require us to make programming changes in order to accommodate those requirements.  If programming changes are needed, most can be accommodated within 2 weeks. We are committed to ensuring agencies can bill to any payor electronically from Generations using the 837p and 837i forms.

837p

The 837p is the electronic version of the CMS1500. 

  • Complete setup instructions are in the CMS1500 Step by Step directions. 
  • Use the CMS1500 Line-by-Line for specific field assistance.
  • Verify that information is correct by reviewing the printed form of the CMS1500.
  • Send at least one test to your billing company before processing a larger group.

Claim Submission & Validation

  • Claims are created via Billing > Billing Report by Client.
  • Generations validates all required fields. If validation errors exist, you must correct them and re-run the report.

Trizetto Clearinghouse Requirements

Trizetto is a clearinghouse and has some special requirements.

  • Box 27 (Accept Assignment – Company 1500 Defaults) must be checked (yes.) If you do not check ‘yes,’ you are giving the payer permission to send payment directly to the client - not to your office.
  • Box 33 Company Name pulls from Company Settings. This must match exactly your name on file with the NPPES (National Plan & Provider Enumerations System). If you are required to have a company name & address in Box 33 different from what is entered in Company Settings, enter that new information on the Client Specific CMS1500.

Sample 837p

Print Image File

The print image export (.TXT)  works with many CMS1500 clearinghouses. Print image files are being phased out as they are being replaced with the 837 format. Please check with your clearinghouse to see which version of the form they use.

  • To produce print image files, complete the fields required for the CMS1500. Follow the CMS1500 Step-by-Step and the CMS1500 Line-by-Line for assistance.
  • Verify that information is correct by reviewing the printed form of the CMS1500.
  • Send at least one test to your billing company before processing a larger group.

New York State Medicaid

The Generations billing export is accepted by Buffalo Intelligent Technology Systems (BITS.) BITS evolved into MedBatch from Founders Software.


Was this article helpful?