Here is Tricare for CMS 1500

Here is Tricare for CMS 1500

Follow the POWER POINT to help complete the CMS-1500 form for

tricare. Then complete the other 3 on your own. Good luck –Mrs. Fogle

Claims InstructionsBlocks 1–3

• Block 1: Enter X in CHAMPUS box

• Block 1a: Enter sponsor’s SSN

• Block 2: Enter patient’s complete name as it appears on the ID card

• Block 3: Enter patient’s DOB as MM DD YYYY (with spaces) and X in appropriate box to indicate gender


• Block 4: Enter sponsor’s complete name; enter SAME if the sponsor is the patient

• Block 5: Enter patient’s mailing address, zip code, area code, and telephone number– Do not enter APO or FPO addresses

• Block 6: Enter X in the appropriate box to indicate patient’s relationship to sponsor


• Block 7: Enter sponsor’s mailing address; enter SAME if sponsor is the patient

• Block 8: Enter X in appropriate box to indicate marital, employment, and/or student status

• Blocks 9–9d: Leave blank

Claims Instructions Blocks 10–12

• Blocks 10a–c: Enter X in the appropriate boxes

• Block 10d: Leave blank

• Blocks 11–11c: Leave blank

• Block 11d: Enter an X in the appropriate box

• Block 12: Enter SIGNATURE ON FILE; leave date blank


• Block 13: Enter SIGNATURE ON FILE; leave date blank

• Block 14: Enter date as MM DD YYYY (with spaces) to indicate date patient first experienced signs/symptoms of illness/injury; enter date of LMP for obstetric visits


• Block 15: Enter date as MM DD YYYY (with spaces) to indicate first date patient had same or similar illness/injury, if documented

• Block 16: Leave blank

Claims InstructionsBlock 17

• Block 17: Enter complete name and credentials of referring provider– If patient was referred by MTF, enter name of

facility and attach DD Form 261 or SF 513

• Block 17a: Enter referring physician’s EIN or SSN


• Block 18: Enter admission and discharge dates as MM DD YYYY (with spaces) if patient was inpatient; if still inpatient, leave TO box blank


• Block 20: Enter X in NO box


• Block 21: Enter ICD code number for diagnosis or conditions treated


• Block 23: Enter prior authorization number or authorization number, if applicable

Claims InstructionsBlocks 24A–24D

• Block 24A: Enter date procedure was performed in FROM box as MMDDYYYY; enter date in TO box if procedure/service was performed on consecutive days

• Block 24B: Enter POS code

• Block 24C: Leave blank

• Block 24D: Enter CPT/HCPCS code(s) and modifier(s)

Claims InstructionsBlocks 24E–24K

• Block 24E: Enter diagnosis reference number (1–4) for the ICD code reported in Block 21

• Block 24F: Enter fee charged to patient’s account for procedure/service performed

• Block 24G: Enter number of units/days

• Blocks 24H-K: Leave blank


• Block 25: Enter billing entity’s EIN or SSN and enter X in appropriate box

• Block 26: Enter patient account number

• Block 27: Enter X in YES box

• Block 28: Enter total charges


• Block 30: Enter balance due

Claims Instructions Blocks 31–32

• Block 31: Enter signature of provider or his/her representative; enter date as MMDDYYYY (without spaces)– TRICARE requires provider’s actual signature

or use of signature stamp on printed claim

• Block 32: Enter name and address of MTF that provided services

Claims Instructions Block 33

• Block 33: Enter provider’s telephone number with area code, official name of billing entity, and mailing address; leave PIN and group numbers blank

Modifications to Claims with Supplemental Coverage

• Block 9: Enter complete name of supplemental policyholder if different from patient; otherwise enter SAME

• Block 9a: Enter ID and group number of supplemental policy

• Block 9b: Enter supplemental policyholder’s DOB as MM DD YYYY; enter X in appropriate box for gender

Modifications to Claims with Supplemental Coverage

• Block 9c: Enter name of supplemental policyholder’s employer

• Block 9d: Enter name of supplemental plan

• Block 10d: Enter the word ATTACHMENT– Attach remittance advice from supplemental

plan to CMS-1500

• Block 11d: Enter X in YES box

Claims Modifications When TRICARE Is Secondary

• Block 11: Enter ID number of health insurance plan primary to TRICARE– If Medicare, enter MEDICARE after number

• Block 11a: If policyholder is not patient, enter primary policyholder’s DOB as MM DD YYYY; enter X in appropriate box to indicate gender (otherwise leave blank)


• Block 11b: Enter name of primary policyholder's employer

• Block 11c: Enter name of primary insurance plan

• Block 11d: Enter X in YES box


• Block 29: Enter reimbursement received from primary insurance plan– Attach remittance advice received from

primary plan to the CMS-1500 claim

Here is Tricare for CMS 1500

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