CMS 1500 Form — Click any box
Patient & Insurance Information
Box 1 Insurance Type
Box 1a Insured's ID Number
Box 2 Patient's Name
Box 3 DOB / Sex
Box 4 Insured's Name
Box 5 Patient Address
Box 6 Relationship to Insured
Box 7 Insured Address
Box 8 Reserved
Box 9 Other Insured Name
Box 9a Other Insured Policy / Group
Box 9b Reserved
Box 9c Reserved
Box 9d Other Insured Plan Name
Box 10 Condition Related To
Box 11 Insured Policy Group
Box 11a Insured DOB/Sex
Box 11b Other Claim ID
Box 11c Insurance Plan Name
Box 11d Another Health Plan?
Signatures & Condition
Box 12 Patient Signature
Box 13 Insured Signature
Illness, Dates & Referring Provider
Box 14 Date of Illness / Injury
Box 15 Other Date
Box 16 Work Absence Dates
Box 17 Referring Provider Name
Box 17b Referring Provider NPI
Box 18 Hospitalization Dates
Box 19 Additional Claim Info
Box 20 Outside Lab?
Diagnosis Codes (Box 21)
Box 21 — ICD-10-CM Diagnosis Codes (A through L)
A B C D E F G H I J K L
Resubmission & Authorization
Box 22 Resubmission Code
Box 23 Prior Authorization Number
Service Lines (Box 24)
24A Date(s)
24B POS
24C EMG
24D CPT / Mod
24E Dx Ptr
24F Charges
24G Units
24H EPSDT
24I ID Qual
24J Rendering NPI
24A
24B
24C
24D
24E
24F
24G
24H
24I
24J
Billing & Provider Information
Box 25 Federal Tax ID
Box 26 Patient Account No.
Box 27 Accept Assignment?
Box 28 Total Charge
Box 29 Amount Paid
Box 30 Reserved
Box 31 Signature of Physician
Box 32 Service Facility
Box 32a Facility NPI
Box 32b Facility Other ID
Box 33 Billing Provider
Box 33a Billing NPI
Box 33b Billing Other ID
Critical field — high denial risk
Selected field
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Click any box on the form to see field-by-field guidance, behavioral health tips, and common mistakes.

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Top 10 CMS 1500 Mistakes in Behavioral Health

Check off each item before submitting — these are the most common reasons BH claims get denied.

Wrong POS for telehealth. POS 10 = patient's home. POS 02 = facility originating site. Most home-based telehealth = 10, not 02.
Group NPI in Box 24J. Box 24J requires the individual (Type 1) NPI of the rendering provider, not the group's organizational NPI.
Missing or mistyped auth number in Box 23. Even one character off causes a CO-15 authorization denial. Copy it exactly.
Patient name mismatch. Box 2 must match the payer's records exactly — no nicknames, no abbreviations.
Wrong date format in Box 14. Use date of first treatment episode for mental health, not today's date or original diagnosis date.
Missing diagnosis pointer in Box 24E. Every service line must be linked to a diagnosis letter (A, B, C...) from Box 21. Leaving it blank = denial.
Missing telehealth modifier (95 or GT). Commercial plans require modifier 95. Medicare requires GT. Never mix them up.
CO-18 duplicate from resubmission without code 7. When correcting a claim, put code 7 (Replacement) in Box 22 with the original claim number — don't resubmit as a new claim.
Blank Boxes 17 / 17b for supervised clinicians. When a supervisee sees the patient, the supervising licensed provider's name and NPI belong in Boxes 17 and 17b.
Wrong or missing taxonomy code. Some payers require a taxonomy code in Box 24I or alongside your NPI. Verify what your specific payer requires for BH services.