Official Medical Billing Standard (Form 02/12)

CMS-1500 Claim Form Generator

Generate and print standardized CMS-1500 (HCFA 1500) healthcare insurance claims for Medicare, Medicaid, and private commercial payers with ICD-10 and CPT coding.

1. Claim Information 🔒 Private In-Browser

Carrier & Insurance Type (Box 1)

Insurance Program

Payer Name & Address (Carrier)

Patient & Policy (Boxes 1a–11)

Insured's I.D. Number (Box 1a)

Patient Relationship to Insured (Box 6)

Patient's Name (Last, First, Middle) (Box 2)

Patient DOB & Sex (Box 3)

Patient Address (Box 5)

Clinical & ICD-10 Diagnoses (Boxes 14 & 21)

Date of Current Illness/Injury (Box 14)

Prior Authorization # (Box 23)

Diagnosis A (Primary ICD-10)

Diagnosis B (Secondary ICD-10)

Services & Billing (Box 24)

Date of Service (24A)

Place of Svc (24B)

CPT / HCPCS (24D)

Diag Pointer (24E)

Charges ($) (24F)

Days/Units (24G)

Billing Provider & Facility (Boxes 25, 31, 33)

Federal Tax ID / EIN (Box 25)

Amount Paid ($) (Box 29)

Billing Provider Name & NPI (Box 33 & 33a)

Mode: Print on Official Pre-Printed Red Drop-Out Paper

When checked, red background borders and labels are hidden so your printer deposits text directly into standard red pre-printed CMS-1500 forms.

HEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12

CARRIER / PAYER NAME & ADDRESS

Blue Cross Blue Shield of Illinois, PO Box 805107, Chicago, IL 60680

1. MEDICARE / MEDICAID / TRICARE / GROUP HEALTH PLAN

[X] GROUP HEALTH PLAN

2. PATIENT'S NAME (Last Name, First Name, Middle Initial)

Reynolds, Katherine M.

5. PATIENT'S ADDRESS (No., Street, City, State, ZIP)

742 Evergreen Terrace, Naperville, IL 60540

1a. INSURED'S I.D. NUMBER

XEX88492019

3. PATIENT'S BIRTH DATE & SEX

06/14/1986 | F

6. PATIENT RELATIONSHIP TO INSURED

[X] Self

14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY

2026-10-01

23. PRIOR AUTHORIZATION NUMBER

AUTH-99214-IL

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (ICD-10-CM)

A. F41.1 (Generalized Anxiety Disorder)

B. F33.1 (Major Depressive Disorder, Recurrent)

24. A-J. SERVICES AND SUPPLIES (CPT / HCPCS / CHARGES)

From Date (A)	To Date	POS (B)	CPT/HCPCS (D)	Modifier	Diag (E)	$ Charges (F)	Days (G)	Rendering NPI (J)
2026-10-26	2026-10-26	11	90834	95	A	$185.00	1	1849201934

25. FEDERAL TAX I.D. NUMBER

36-9876543 (EIN)

28. TOTAL CHARGE

$185.00

29. AMOUNT PAID / 30. BALANCE

Paid: $25.00 | Bal: $160.00

31. SIGNATURE OF PHYSICIAN OR SUPPLIER

Signature on File

Date: 2026-10-26

33. BILLING PROVIDER INFO & PH #

Midwest Behavioral Health Associates LLC | NPI: 1849201934

Understanding the CMS-1500 (HCFA-1500) Health Insurance Claim Form

The CMS-1500 Form is the official standard paper claim form prescribed by the Centers for Medicare & Medicaid Services (CMS) and used by virtually all commercial health insurance carriers (Aetna, Cigna, UnitedHealthcare, Blue Cross Blue Shield) to bill for medical, behavioral health, and therapeutic services.

Key Data Sections on Form CMS-1500 (02/12)

Patient & Insured Demographics (Boxes 1–13): Identifies policy numbers, group numbers, patient relationship to the insured, and third-party payer coordination of benefits.
Clinical Diagnoses (Box 21): Supports up to 12 ICD-10-CM diagnosis codes labeled A through L, establishing medical necessity for each line of treatment.
Service Line Table (Box 24): Documents each specific date of service, place of service code (e.g., 11 for Office, 02 for Telehealth), CPT/HCPCS procedure codes, diagnosis pointers, charges, and rendering provider 10-digit National Provider Identifier (NPI).
Billing Entity Certification (Boxes 25–33): Federal Tax ID (EIN or SSN), total charges, balance due, and billing provider practice credentials.

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CMS-1500 Claim Form Generator

1. Claim Information 🔒 Private In-Browser

HEALTH INSURANCE CLAIM FORM

Understanding the CMS-1500 (HCFA-1500) Health Insurance Claim Form

Key Data Sections on Form CMS-1500 (02/12)

What is the Cms 1500 Generator & Why Does It Exist?

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