1. 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

2. Claims Instructions Blocks 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

3. Claims Instructions Blocks 4–6 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

4. Claims Instructions Blocks 7–9 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

5. 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

6. Claims Instructions Blocks 13–14 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

7. Claims Instructions Blocks 15–16 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

8. Claims Instructions Block 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

9. Claims Instructions Blocks 18–20 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 19: Leave blank Block 20: Enter X in NO box

10. Claims Instructions Blocks 21–23 Block 21: Enter ICD code number for diagnosis or conditions treated Block 22: Leave blank Block 23: Enter prior authorization number or authorization number, if applicable

11. Claims Instructions Blocks 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)

12. Claims Instructions Blocks 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

13. Claims Instructions Blocks 25–30 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 29: Leave blank Block 30: Enter balance due

14. 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

15. 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

16. 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

17. 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

18. 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)

19. Claims Modifications When TRICARE Is Secondary Block 11b: Enter name of primary policyholder's employer Block 11c: Enter name of primary insurance plan Block 11d: Enter X in YES box

20. Claims Modifications When TRICARE Is Secondary Block 29: Enter reimbursement received from primary insurance plan –Attach remittance advice received from primary plan to the CMS-1500 claim