A Guide to the CMS 1450 Claim Form

Step-by-step instructions for filling out the CMS 1450 form.

The CMS-1450 (UB-04) is used to submit hospital and medical facility charges for inpatient and outpatient services.

Each insurance provider requires different information to be completed. Some may even require a different form.

The information necessary for claim completion is not universal amongst insurance providers. Verify the required data fields with each insurance company before submitting a claim.

The following information is a guide to the CMS-1450; each section is not required by all insurance providers:

  • FL 1: Enter the Billing Provider information in the following order -

    • Line 1: Facility name
    • Line 2: Street address
    • Line 3: City, State and zip code
    • Line 4: telephone number

  • FL 2: If different from FL 1, enter the address in which it is to be sent to. Use the following format -

    • Line 1: Pay-to name
    • Line 2: street address or PO Box
    • Line 3: City, State, and zip
    • Line 4: leave blank

  • FL 3a: Enter the patient account number assigned by the office.

  • FL 3b: Enter the patient's medical/health record number assigned by the office.

  • FL 4: Enter the appropriate code for the type of bill.

  • FL 5: Enter the hospital/facility's federal tax or Employer ID number.

  • FL 6: Enter the dates indicating when services were provided.

  • FL 7: Reserved for assignment by the National Uniform Billing Committee (NUBC). Leave Blank.

  • FL 8a: Enter the patient ID number if it is different than that of the policy holder's ID number for FL 60.

  • FL 8b: Enter the patient's name (last, first, middle initial).

  • FL 9 (a-e):Enter the patient's address -

    • Line a: street address
    • Line b: city
    • Line c: state
    • Line d: zip code
    • Line e: country code (use if outside the US)

  • FL 10: Enter the patient's DOB.

  • FL 11: Enter the patient's sex - "M" for male, "F" for female, "U" for unknown.

  • FL 12: Enter the admission date for this episode of care. Use the "MMDDYY" format.

  • FL 13: Enter the hour the patient was admitted.

  • FL 14: Enter the code to indicate the priority of the patient encounter (e.g. the code 5 indicates a trauma).

  • FL 15: Enter the code to indicate the source of transfer for this visit.

  • FL 16: Enter the code indicating the hour of discharge.

  • FL 17: Enter the code indicating the patient's status upon discharge.

  • FL 18-28: Enter condition codes in alphanumeric order. If necessary use FL 81 with the appropriate qualifier code to indicate a condition code is being reported.

  • FL 29: Enter the appropriate code to indicate the state the accident occurred in.

  • FL 30: Reserved for assignment by the National Uniform Billing Committee (NUBC). Leave blank.

  • FL 31-34 (a-b): Enter occurrence codes in alphanumeric order along with the corresponding dates in "MMDDYY" format.

  • FL 35-36 (a-b): Enter the occurrence span dates in alphanumeric order using the "MMDDYY" format.

  • FL 37: Reserved for assignment by the National Uniform Billing Committee (NUBC). Leave blank.

  • FL 38 (1-5): Enter the name and address of the person responsible for paying the bill.

  • FL 39-41 (a-d): Enter value codes and related amounts. This is done in alphanumeric order.

  • FL 42: Enter the 4-digit revenue code listed in numerical order on line 1 through 23. The last line should indicate the Total Charge and have the code 0001. The last line should also include the claim page numbers, the claim generation date, and the total charges in the covered and non-covered charge columns.

  • FL 43: Enter the standard abbreviation descriptions for each revenue code.

  • FL 44: Enter the HCPCS codes and any appropriate modifiers for outpatient claims. Enter the HCPCS code, health insurance prospective payment system rate code where applicable, or the daily accommodation rate for inpatient claims.

  • FL 45: Enter the service date (MMDDYY).

  • FL 46: Enter the service units (this can be days, quantity of item, dosage, etc.).

  • FL 47: Enter the total charge amount for all items in the revenue code section on line 23.

  • FL 48: Enter the total of non-covered charges (located on line 23) with the matching code 0001.

  • FL 49: Reserved for assignment by the National Uniform Billing Committee (NUBC). Leave blank.

  • FL 50: List the primary payer and ID number on line A. List any additional payers and their ID numbers on lines B and C.

  • FL 51: Enter the healthcare ID number. Line A - Primary payer. Line B - Secondary payer. Line C - Tertiary payer.

  • FL 52: Enter the appropriate release of information certification indicator.

  • FL 53: Enter the appropriate assignment of benefits certification indicator.

  • FL 54: Enter any prior payments made by the patient. Line A - primary payer. Line B - Secondary payer. Line C - Tertiary payer. You will need to submit an original or reproduced copy of the EOB or EOMB with a paper claim if Blue Cross is a secondary payer.

  • FL 55: Enter the estimated amount due. Line A - Primary payer. Line B - Secondary payer. Line C - Tertiary payer.

  • FL 56: Enter the healthcare provider's National Provider ID number.

  • FL 57: Enter the ID number assigned to the provider by the health plan. Line A - primary payer. Line B - Secondary payer. Line C - tertiary payer.

  • FL 58: Enter the policy holder's name. List the last name first followed by the first and middle initial. (Smith, John J.) Line A - Primary payer. Line B - Secondary Payer. Line C - Tertiary Payer.

  • FL 59: Enter the appropriate two-digit code indicating the patient's relationship to the policy holder. Line A - Primary payer. Line B - Secondary Payer. Line C - Tertiary Payer.

  • FL 60: Enter the policy holder's ID number that matches the name in FL 58. Enter the valid member ID number exactly how it appears on the ID card. Line A - Primary payer. Line B - Secondary Payer. Line C - Tertiary Payer.

  • FL 61: Enter the policy holder's group name (s). Line A - Primary payer. Line B - Secondary Payer. Line C - Tertiary Payer.

  • FL 62: Enter the policy holder's group number(s). Line A - Primary payer. Line B - Secondary Payer. Line C - Tertiary Payer.

  • FL 63: Enter the treatment authorization code provided by the payer. Line A - Primary payer. Line B - Secondary Payer. Line C - Tertiary Payer.

  • FL 64: Enter the document control number assigned to the original claim by the payer. Line A - Primary payer. Line B - Secondary Payer. Line C - Tertiary Payer.

  • FL 65: Enter the policy holder's employer name. Line A - Primary payer. Line B - Secondary Payer. Line C - Tertiary Payer.

  • FL 66: Enter the ICD version indicator. Enter "9" for the 9th revision and "0" for the 10th revision.

  • FL 67: Enter the principle diagnosis code that corresponds with the patient's initial diagnosis. Do not key the decimal point. Inpatient claims require a POA (present on admission) indicator; use the following: "Y" - condition was present on admissions; "N" - condition not present on admission; "U" - no information on the record; "W" - condition was clinically undetermined.

  • FL 68: Reserved for assignment by the National Uniform Billing Committee (NUBC). Leave blank.

  • FL 69: Enter the ICD diagnosis codes that describe the reason the patient was admitted.

  • FL 70: Enter the ICD diagnosis code for the patient's reason to visit at the time of the outpatient registration.

  • FL 71: For inpatient admission, enter the PPS (prospective payment system) code.

  • FL 72 (a-c): Enter the ICD external cause of injury (E-code) and POA code for the patient's condition.

  • FL 73: Reserved for assignment by the National Uniform Billing Committee (NUBC). Leave Blank.

  • FL 74: Using the ICD-9-CM manual (or ICD-10 if it's in effect), enter the primary procedure code and date it was performed. Use the MMDDYY format when recording the date. The decimal within the code is implied and does not need to be used.

  • FL 74 (a-e): Enter any other ICD procedure codes that correspond to any other significant procedures performed during the patient encounter. Use the MMDDYY format when recording the date. The decimal within the code is implied and does not need to be used.

  • FL 75: Reserved for assignment by the National Uniform Billing Committee (NUBC). Leave blank.

  • FL 76: Enter the attending physician's name (last, first, middle initial) and NPI number. The attending physician is the physician responsible for the patient's care while an inpatient. Enter the physician's ID number(s) on the top line and their name on the bottom line.

  • FL 77: Enter the operating physician's name (last, first, middle initial) and NPI number. Enter the physician's ID number(s) on the top line and their name on the bottom line.

  • FL 78-79: Enter the other provider's (individual) type qualifier, NPI number, and secondary identifier qualifiers in the top row. Enter the other provider name (last, first) in the bottom row. The provider type qualifiers are as follows: "DN" - referring provider; "ZZ" - other operating physician; "82" - rendering provider. The Secondary ID Qualifiers are as follows: "OB" - state license number; "1G" - UPIN; "G2" - provider commercial number.

  • FL 80: Enter any additional information required by the payer for the claim to be processed. Remarks in this field should be payer specific.

  • FL 81: Enter any additional condition or occurrence codes.

The CMS 1450 claim form






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