Cms 1500 Claim Filing Instructions Page 8
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1
2
3
4
5
6
7
8
928
Required
Total Charge
The sum of all line item charges (Box 24f 1-6) on this claim.
29
Required if
Amount Paid
applicable
The amount the provider has received from the patient or insured
toward the total payment of this claim. Note that the amount
entered on the claim must match the amount indicated on the
other carrier EOB.
30
Not Required
Balance Due
The amount of difference between the total charges (28) and the
amount paid (29) to the provider for this claim.
31
Required
Signature of Physician or Supplier Including Degrees or
(including
Credentials
clinician’s
The signature of the physician or clinician who performed the
credentials)
services on the claim.
If a group practice name appears in Box 33, the name of the
provider who performed the services must appear in Box 31.
32
Required if
Service Facility Location Information
applicable
Name of facility other than the patient’s home or physician’s
office, where services were performed, such as hospital or clinic.
32a
Required if
NPI#
applicable
NPI# of the service facility location.
32b
Not Required
Other ID#
Do not enter a provider ID number in this field.
33
Required
Billing Provider Info and Phone #
8
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