Health Insurance Claim Form Guide: CMS-1500 & UB-04 Templates (2025)

Quick Answer: Health Insurance Claim Forms

Health insurance claim forms are standardized documents used to bill insurance companies for healthcare services. The two primary forms are the CMS-1500 (for professional/physician services) and the UB-04/CMS-1450 (for institutional/facility claims). Key elements include patient demographics, insurance information, diagnosis codes (ICD-10), procedure codes (CPT/HCPCS), dates of service, provider information (NPI), and charges. Accurate claim submission requires correct coding, complete patient information, and proper documentation to support medical necessity.

What Are Health Insurance Claim Forms?

Health insurance claim forms are standardized billing documents healthcare providers submit to insurance companies requesting payment for medical services rendered to patients. The Centers for Medicare & Medicaid Services (CMS) mandates two universal forms: the CMS-1500 for professional services delivered by physicians, nurse practitioners, therapists, and other non-institutional providers, and the UB-04 (CMS-1450) for institutional services provided by hospitals, skilled nursing facilities, and home health agencies, containing required data elements including patient demographics, insurance policy information, diagnostic justification using ICD-10-CM codes, service descriptions via CPT/HCPCS codes, National Provider Identifiers (NPIs), dates of service, and itemized charges formatted according to HIPAA Electronic Data Interchange (EDI) standards.

How to Complete Health Insurance Claim Forms Accurately

Completing health insurance claim forms accurately requires systematic attention to detail and understanding of payer-specific requirements:

Verify Patient Eligibility and Benefits: Before service delivery, confirm active insurance coverage through real-time eligibility verification systems, checking plan effective dates, coverage limitations, copayment amounts, deductible status, prior authorization requirements, and ensuring the patient’s demographic information (name, date of birth, policy number) matches insurance company records exactly as any discrepancy triggers automatic claim rejection.
Ensure Complete Clinical Documentation: Accurate claims begin with comprehensive medical records documenting the patient encounter—the chief complaint, history of present illness, examination findings, medical decision-making, treatment provided, and follow-up plans—because coding accuracy depends entirely on documentation completeness, with unclear or incomplete records leading to unspecified diagnosis codes, incorrect procedure code selection, and medical necessity denials.
Assign Accurate Diagnosis and Procedure Codes: Select ICD-10-CM diagnosis codes at the highest level of specificity available (avoiding unspecified codes when documentation supports more precise codes), list the primary diagnosis first followed by secondary diagnoses affecting clinical decision-making or resource utilization, assign CPT or HCPCS codes that precisely match documented services, apply appropriate modifiers indicating special circumstances (bilateral procedures, distinct services, professional vs. technical components), and verify diagnosis codes support medical necessity for each procedure through proper diagnosis pointer linkage in Box 24E.
Complete Required Form Fields: For CMS-1500 claims, populate all mandatory fields including patient information (Boxes 1-13), clinical information (Boxes 14-23), detailed service lines with dates, procedure codes, diagnosis pointers, and charges (Box 24A-J), and provider information with valid NPIs (Boxes 25-33); for UB-04 claims, complete facility information, patient demographics, admission/discharge data, condition and occurrence codes, revenue codes with HCPCS, diagnosis codes, and provider NPIs following Medicare’s Uniform Billing guidelines.
Validate Data Accuracy Through Claim Scrubbing: Before electronic submission, run claims through automated scrubbing software that checks for missing required fields, invalid code combinations, incorrect code formats, diagnosis-procedure mismatches, outdated codes beyond their valid date ranges, duplicate claims, invalid provider NPIs, and payer-specific edits—catching errors that would cause immediate rejections and enabling correction before submission, significantly improving first-pass acceptance rates and reducing rework.
Submit Claims Through Appropriate Channels: Transmit electronic claims via HIPAA-compliant clearinghouses using standardized ANSI X12 837P format for professional claims and 837I for institutional claims, or mail paper claims to payer-specific addresses when electronic submission isn’t available, tracking submission dates carefully because each payer enforces strict timely filing limits (typically 90-365 days from date of service) with automatic denials for late submissions regardless of claim validity.
Monitor Claim Status and Respond to Denials: Track submitted claims through practice management systems, respond promptly to payer requests for additional documentation, analyze remittance advice (ERA/EOB) to identify denial reasons, appeal inappropriate denials within payer deadlines (usually 30-180 days), and document denial patterns to address systematic issues through improved documentation, staff training on coding updates, or workflow modifications—recognizing that proactive denial management recovers revenue and prevents future claim rejections.

Introduction

Understanding health insurance claim forms is essential for healthcare providers, billing staff, and practice managers. According to the Medical Group Management Association (MGMA), improper claim submission represents one of the leading causes of revenue loss in medical practices, with clean claim rates averaging only 75-85% on initial submission—meaning 15-25% of claims require rework, resubmission, or result in denials that delay reimbursement by 30-60 days.

Proper claim submission directly impacts revenue cycle management, reimbursement timelines, and denial rates. Healthcare Financial Management Association (HFMA) data shows that each denied claim costs practices $25-$118 to rework when accounting for staff time investigating denial reasons, gathering additional documentation, appealing denials, and resubmitting corrected claims, with some complex denials requiring physician involvement adding hundreds of dollars in lost productivity.

This comprehensive guide covers the CMS-1500 and UB-04 claim forms, field-by-field completion instructions, common errors to avoid, and best practices for clean claim submission. Whether you’re new to medical billing or looking to reduce claim denials, this guide provides the documentation knowledge you need.

Types of Health Insurance Claim Forms

CMS-1500 (Professional Claims)

The CMS-1500 is used for professional services provided by physicians, nurse practitioners, physician assistants, therapists, and other non-institutional providers. It’s the standard form for outpatient office visits, consultations, procedures performed in physician offices, and professional services rendered in any setting.

UB-04/CMS-1450 (Institutional Claims)

The UB-04 (also called CMS-1450) is used by institutional providers including hospitals (inpatient and outpatient), skilled nursing facilities, home health agencies, hospice, and other facility-based services. It captures facility charges, room and board, and technical components of services.

Electronic vs. Paper Claims

While paper forms still exist, most claims are now submitted electronically using the ANSI X12 837P (professional) and 837I (institutional) formats. According to CMS statistics, over 98% of Medicare claims are submitted electronically as of 2024, with electronic submission mandatory for most HIPAA-covered entities. Electronic claims reduce errors, speed processing to 14-21 days compared to 30-45 days for paper claims, and are required by many payers. The field concepts remain the same whether submitting paper or electronic claims.

CMS-1500 Form: Complete Field Guide

Header Section (Boxes 1-13): Patient and Insurance Information

Box 1: Type of Insurance
Check the appropriate box: Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA Black Lung, or Other. For secondary claims, indicate the primary payer type.

Box 1a: Insured’s ID Number
Enter the primary insured’s identification number exactly as it appears on the insurance card. For Medicare, this is the Medicare Beneficiary Identifier (MBI). According to AHIMA, mismatched policy numbers account for 18% of initial claim rejections, making this one of the most critical fields for clean claim submission.

Box 2: Patient’s Name
Enter patient’s last name, first name, and middle initial as shown on the insurance card. Use commas to separate: LastName, FirstName, MI.

Box 3: Patient’s Birth Date and Sex
Enter date of birth in MM/DD/YYYY format. Check M for male or F for female.

Box 4: Insured’s Name
If the patient is the insured, enter “SAME.” Otherwise, enter the policyholder’s name in LastName, FirstName, MI format.

Box 5: Patient’s Address
Enter the patient’s complete mailing address including street, city, state, ZIP code, and telephone number.

Box 6: Patient Relationship to Insured
Check: Self, Spouse, Child, or Other to indicate the patient’s relationship to the policyholder.

Box 7: Insured’s Address
If same as patient, enter “SAME.” Otherwise, enter the insured’s complete address and phone number.

Box 8: Reserved for NUCC Use
Leave blank unless specific payer instructions indicate otherwise.

Box 9: Other Insured’s Name
If the patient has secondary insurance, enter that policyholder’s name. Leave blank if no secondary coverage.

Box 9a: Other Insured’s Policy or Group Number
Enter the policy or group number of the secondary insurance.

Box 9b: Reserved for NUCC Use
Leave blank.

Box 9c: Reserved for NUCC Use
Leave blank.

Box 9d: Other Insurance Plan Name
Enter the name of the secondary insurance plan or program.

Box 10a-c: Is Patient’s Condition Related To
Check Yes or No for: (a) Employment, (b) Auto Accident (include state), (c) Other Accident. Important for liability and workers’ compensation claims.

Box 10d: Claim Codes
Reserved for special claim codes when applicable.

Box 11: Insured’s Policy, Group, or FECA Number
Enter the primary insured’s policy or group number from the insurance card.

Box 11a: Insured’s Date of Birth and Sex
Enter if different from patient (Box 3).

Box 11b: Other Claim ID
Enter other claim ID designated by NUCC when applicable.

Box 11c: Insurance Plan Name or Program Name
Enter the name of the insurance plan or program.

Box 11d: Is There Another Health Benefit Plan?
Check Yes or No. If Yes, complete boxes 9a-9d.

Box 12: Patient’s or Authorized Person’s Signature
“Signature on File” or “SOF” is acceptable if a signed authorization is in the patient’s record. This authorizes release of medical information.

Box 13: Insured’s or Authorized Person’s Signature
Authorization for payment to be made directly to the provider. “Signature on File” acceptable with documented authorization.

Provider and Clinical Section (Boxes 14-33)

Box 14: Date of Current Illness, Injury, or Pregnancy (LMP)
Enter the date when symptoms first appeared, injury occurred, or last menstrual period for pregnancy. Use qualifiers: 431 (Onset of Current Symptoms/Illness), 484 (Last Menstrual Period).

Box 15: Other Date
Enter another date related to the patient’s condition with appropriate qualifier.

Box 16: Dates Patient Unable to Work
Enter From and To dates if the patient is employed and unable to work due to the condition being treated. Important for disability claims.

Box 17: Name of Referring Provider or Other Source
Enter the name and credentials of the referring, ordering, or supervising provider when applicable.

Box 17a: (blank) / 17b: NPI
Enter the NPI of the provider listed in Box 17.

Box 18: Hospitalization Dates Related to Current Services
If services are related to a hospitalization, enter admission and discharge dates.

Box 19: Additional Claim Information
Enter additional information required by specific payers or for specific claim types.

Box 20: Outside Lab?
Check Yes if lab work was performed by an outside laboratory. Enter charges if Yes.

Box 21: Diagnosis or Nature of Illness or Injury
Enter up to 12 ICD-10-CM diagnosis codes (A through L). List the primary diagnosis first. Use the highest level of specificity available. Black Book Research reports that claims with unspecified diagnosis codes face 35-40% higher denial rates compared to claims using specific codes, because payers increasingly require precise diagnostic justification for medical necessity determination.

Box 22: Resubmission Code and Original Reference Number
For corrected claims or replacements, enter the appropriate frequency code and original claim number.

Box 23: Prior Authorization Number
Enter the prior authorization, precertification, or referral number if required by the payer.

Service Line Section (Box 24A-J)

Box 24A: Dates of Service
Enter From and To dates for each service line in MM/DD/YY format. For single-date services, enter the same date in both fields.

Box 24B: Place of Service
Enter the two-digit Place of Service (POS) code:
– 11 = Office
– 12 = Home
– 21 = Inpatient Hospital
– 22 = Outpatient Hospital
– 23 = Emergency Room
– 31 = Skilled Nursing Facility
– 81 = Independent Laboratory
– 02 = Telehealth (patient home)

Box 24C: EMG
Check if services were rendered on an emergency basis.

Box 24D: Procedures, Services, or Supplies
Enter the CPT or HCPCS code for each service. Include modifiers in the modifier fields (up to 4 modifiers per line).

Box 24E: Diagnosis Pointer
Enter the letter(s) from Box 21 (A-L) that correspond to the diagnosis codes supporting medical necessity for this service. List primary diagnosis first. MGMA research shows that incorrect diagnosis pointer linkage accounts for 12-15% of medical necessity denials, as payers’ automated systems reject claims when the diagnosis-procedure relationship doesn’t meet their coverage criteria.

Box 24F: Charges
Enter the charge amount for each service line. Do not include dollar signs or decimals—the form assumes dollars and cents.

Box 24G: Days or Units
Enter the number of days or units for the service. For most services, this is 1. For time-based services, enter the number of units based on time increments.

Box 24H: EPSDT/Family Plan
For Medicaid EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) claims, enter the appropriate referral code.

Box 24I: ID Qualifier
Leave blank if using NPI in 24J. Otherwise, enter the appropriate qualifier for non-NPI identification.

Box 24J: Rendering Provider ID
Enter the NPI of the rendering provider (the individual who performed the service) in the unshaded area.

Provider Information (Boxes 25-33)

Box 25: Federal Tax ID Number
Enter the provider’s or practice’s EIN or SSN. Check the appropriate box to indicate which type.

Box 26: Patient’s Account Number
Enter the patient’s account number from your practice management system. This number appears on the remittance advice.

Box 27: Accept Assignment?
Check Yes if the provider accepts assignment (agrees to accept the payer’s allowed amount as payment in full). Required for Medicare participating providers.

Box 28: Total Charge
Enter the total of all charges from Box 24F.

Box 29: Amount Paid
Enter any amount the patient has already paid or payments from other insurance.

Box 30: Reserved for NUCC Use
Leave blank.

Box 31: Signature of Physician or Supplier
Provider signature and date. “Signature on File” acceptable with documented authorization. Electronic claims require electronic signature.

Box 32: Service Facility Location Information
Enter the name, address, and NPI of the facility where services were rendered if different from Box 33.

Box 32a: Service Facility NPI
Enter the NPI of the service facility.

Box 32b: Other ID
Enter other identifying number if required by payer.

Box 33: Billing Provider Info and Phone Number
Enter the billing provider’s or practice’s name, address, phone number, and NPI. This is where payment will be sent.

Box 33a: Billing Provider NPI
Enter the NPI of the billing provider or group.

Box 33b: Other ID
Enter other identifying number if required by specific payer.

UB-04 Form: Institutional Claims Overview

Key Form Locators

FL 1: Billing Provider Name and Address
Facility name and address.

FL 2: Pay-to Name and Address
Enter if payment should go to a different address than FL 1.

FL 3a-b: Patient Control Number
Patient’s account number and medical record number.

FL 4: Type of Bill
Four-digit code indicating type of facility, bill classification, and frequency:
– First digit: Type of facility (1=Hospital, 2=SNF, 3=Home Health, 8=Hospice)
– Second digit: Bill classification (1=Inpatient, 3=Outpatient, 4=Other)
– Third digit: Frequency (1=Admit through discharge, 2=Interim first, 7=Replacement)

FL 5: Federal Tax ID
Facility’s EIN.

FL 6: Statement Covers Period
From and through dates for the billing period.

FL 8-11: Patient Information
Patient name, address, date of birth, sex.

FL 12-16: Admission Information
Admission date, admission hour, type of admission, source of admission, discharge hour.

FL 17: Patient Discharge Status
Two-digit code indicating where patient went after discharge (01=Home, 02=Short-term hospital, 03=SNF, 20=Expired, 30=Still patient).

FL 18-28: Condition Codes
Codes describing conditions affecting claim processing.

FL 31-34: Occurrence Codes and Dates
Codes and dates for significant events (accident date, admission date, etc.).

FL 35-36: Occurrence Span Codes
From and through dates for qualifying events.

FL 39-41: Value Codes and Amounts
Monetary values affecting claim (deductible amounts, coinsurance, etc.).

FL 42-49: Revenue Codes and Service Lines
Revenue codes, HCPCS/CPT codes, service dates, units, and charges for each service category.

FL 50-65: Payer Information
Primary, secondary, and tertiary payer information including name, ID numbers, and insurance type.

FL 66: Diagnosis and Procedure Code Qualifier
Indicates ICD version (0 = ICD-10).

FL 67: Principal Diagnosis Code
Primary ICD-10-CM code.

FL 67A-Q: Other Diagnosis Codes
Secondary diagnoses.

FL 69: Admitting Diagnosis
Diagnosis at time of admission (may differ from principal diagnosis).

FL 70a-c: Patient Reason for Visit
Outpatient reason for visit codes.

FL 74: Principal Procedure Code and Date
ICD-10-PCS code for principal inpatient procedure.

FL 74a-e: Other Procedure Codes
Additional ICD-10-PCS procedure codes.

FL 76-79: Attending, Operating, and Other Providers
Provider NPIs and names.

Essential Coding for Claim Forms

ICD-10-CM Diagnosis Codes

Diagnosis codes establish medical necessity for services. Use the most specific code available (highest level of specificity). List the primary diagnosis first, followed by secondary diagnoses that affect treatment or resource utilization. Common coding errors include using unspecified codes when more specific codes are available and failing to code all relevant diagnoses. Healthcare organizations implementing computer-assisted coding (CAC) systems see 30-40% improvement in coding specificity because AI analyzes complete clinical documentation to suggest precise codes rather than relying on coder interpretation of abbreviated encounter forms.

CPT Procedure Codes

Current Procedural Terminology (CPT) codes describe professional services. Use the code that most accurately describes the service performed. Evaluation and Management (E/M) codes are selected based on medical decision-making complexity or time for outpatient services. Procedure codes should match the documentation in the medical record.

HCPCS Level II Codes

Healthcare Common Procedure Coding System (HCPCS) Level II codes cover supplies, drugs, durable medical equipment, and services not included in CPT. These alphanumeric codes (beginning with letters) supplement CPT codes for complete claim submission.

Modifiers

Modifiers provide additional information about services without changing the code definition. Common modifiers include:
– 25: Significant, separately identifiable E/M service
– 59: Distinct procedural service
– 76: Repeat procedure by same physician
– LT/RT: Left side/Right side
– TC: Technical component
– 26: Professional component

Common Claim Errors and How to Avoid Them

Patient Information Errors

Mismatched patient name or date of birth with insurance records causes immediate denials. Always verify patient demographics against the insurance card at every visit. Ensure the subscriber ID is entered exactly as shown on the card. AHIMA reports that demographic errors account for approximately 22% of claim denials, representing easily preventable revenue delays that automated eligibility verification systems can virtually eliminate by checking patient information against payer databases before services are rendered.

Coding Errors

Using outdated codes, incorrect diagnosis-procedure linkage, or non-specific codes leads to denials or reduced reimbursement. Verify codes are current and appropriate for the date of service. Ensure diagnosis codes support medical necessity for each procedure. Incomplete clinical documentation at the point of care leads to coding errors downstream, because coders must select codes based on limited information—which is why healthcare organizations increasingly adopt AI medical scribe systems that capture comprehensive encounter details in real-time, providing coders with complete documentation that enables accurate code selection and supports medical necessity.

Missing or Invalid Information

Blank required fields, invalid NPI numbers, or missing prior authorization numbers cause preventable denials. Use claim scrubbing software to catch errors before submission. Verify all required fields are completed accurately.

Timely Filing

Each payer has specific timely filing requirements (often 90 days to one year from date of service). Track filing deadlines carefully. Late submissions result in automatic denials with no appeal rights. HFMA data shows that 5-7% of total charges are lost annually due to timely filing denials, representing millions in unrecoverable revenue for large healthcare organizations—losses that comprehensive revenue cycle management systems prevent through automated claim tracking and filing deadline alerts.

Best Practices for Clean Claims

Verify patient eligibility and benefits before providing services. Confirm coverage is active and understand any prior authorization requirements. Update patient demographic and insurance information at each visit.

Ensure documentation supports all services billed. Medical necessity must be clearly established in the clinical documentation. Code directly from the medical record, not from encounter forms or superbills alone. Complete clinical documentation captured during patient encounters reduces downstream coding queries, eliminates ambiguity in code selection, and provides the medical necessity justification payers require—which is why practices using comprehensive documentation systems see 15-25% higher clean claim rates compared to practices relying on abbreviated templates or checkbox encounter forms.

Implement a claim scrubbing process before submission. Review claims for completeness, coding accuracy, and payer-specific requirements. Many practice management systems include built-in scrubbing tools that compare claims against payer-specific edits before electronic transmission, catching errors that would cause rejections and enabling correction before submission—improving first-pass acceptance rates from typical 75-85% to 92-98%.

Monitor denial trends and address root causes. Track common denial reasons and implement corrective actions. Staff training on proper documentation and coding reduces preventable denials. Healthcare organizations that systematically analyze denial patterns identify recurring issues like specific procedure-diagnosis combinations triggering medical necessity denials, payer-specific authorization requirements, or documentation gaps requiring targeted improvements—addressing root causes rather than repeatedly working individual denials.

Frequently Asked Questions

When should I use CMS-1500 vs. UB-04?

Use CMS-1500 for professional services (physician, NP, PA, therapist services). Use UB-04 for facility/institutional charges (hospital, SNF, home health, hospice). When a physician provides services in a hospital, the physician bills CMS-1500 for professional services while the hospital bills UB-04 for facility charges.

How many diagnosis codes can I include on a claim?

The CMS-1500 allows up to 12 diagnosis codes (A through L in Box 21). The UB-04 allows one principal diagnosis and up to 24 additional diagnosis codes. Include all diagnoses that affect the current encounter or require clinical evaluation or management.

What is the difference between billing and rendering provider?

The billing provider (Box 33) is the entity submitting the claim and receiving payment—typically the practice or facility. The rendering provider (Box 24J) is the individual who actually performed the service. For solo practitioners, these may be the same, but for group practices, they are often different.

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Disclaimer: This guide is for educational purposes. Payer requirements vary and change frequently. Always verify current requirements with specific payers and consult with certified coding professionals for complex billing scenarios.