CMS 1500 - Instruction on the proper completion of the CMS 1500 claim form can be found in the “Introduction to Medicare” and/or “1500 Claim Form Instructions” at
http://www.medicarenhic.com/ne_prov/publications.shtml for New England providers. Providers should follow the instructions outlined in either of these two publications. Special consideration should be made to the following fields for claim submission by ambulance providers:
ITEM # DATA TO INCLUDE
Item 19 Although not mandated by CMS some ambulance providers utilize this item to give us information regarding the patient’s condition at the time of transports and/or justification for ALS1, ALS2 or SCT transports or facility to facility transports.
Item 23 CMS mandates the entry of the “zip code” for the point of pick up in this field. Since the ZIP code is used for pricing, more than one ambulance service may be reported on the same claim for a beneficiary if all points of pickup have the same ZIP code. Supplies must prepare a separate claim for each trip if the points of pickup are located in different ZIP codes. Claims without a ZIP code in item 23, or with multiple ZIP codes in item 23, will be returned as unprocessable.
Item 24G# of loaded miles
Item 32 Although not mandated by CMS some ambulance providers utilize this item to give us the names, city, state and zip codes for the points of pick up and destination.
The CMS 1500 claim form may be ordered from an office supply store or one of the following organizations:
US Government Printing Office American Medical Association
Superintendent of Documents Attention: Order Department
Washington, DC 20402 PO Box 10946
202-512-1800 Chicago, IL 60610