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Completing the
CMS-1500 Claim Form

The CMS-1500 form is a health insurance claim form. It is used to report and bill medical claims prepared and submitted by most physicians and suppliers for a physician's professional services. [12]

Steps to Complete the CMS-1500 Claim Form [11,13]

Example of a Health Insurance Claim Form [11] View Full Form

Step 1: Complete the top half of the claim form with the patient's information

Step 2: Report the diagnosis codes along with any other diagnoses relevant to the patient's episode of care on this date of service (see the section of the claim form titled "Diagnosis or Nature of Illness or Injury")

Step 3: Report the CPT codes for the vaccines administered—eg, the product code (see the section of the claim form titled "Procedures, Services, or Supplies")

Add the appropriate CPT codes for E/M services, ancillary services, and vaccine administration considering age, counseling, and route of administration (see the section of the claim form titled "Procedures, Services, or Supplies")
Confirm whether any additional E/M services were provided

Step 4: Append any necessary modifiers for proper claim processing

Step 5: Link the CPT codes to an ICD-10 code to support medical necessity (see the section of the claim form titled "Diagnosis Pointer" or "Diagnosis Code")

Step 6: Sign (if necessary) and submit the claim form per the insurance carrier's/insurer's instruction

Step 7: Enter the NDC, if required

More Information on National Drug Codes (NDCs)
Some payers may require reporting of National Drug Codes (NDCs) for vaccine products. GSK vaccines typically have 10-digit NDCs, which represent the various product presentations (eg, vial, syringe). For example, one product may have several NDCs to reflect each presentation available. (There is also a separate NDC for the outer packaging for each presentation. It is important to check with your payers to understand which NDC is acceptable when completing a claim form.) When reporting NDCs per individual payer requirements, NDCs must be documented in an 11-digit format, which requires adding a "0." For GSK vaccines, this involves adding a "0" immediately after the first hyphen in each NDC. Please note that on the CMS-1500 claim form, no spaces or hyphens should be used when adding an NDC. On the
CMS-1500 claim form, the NDC may be added in Section 24 within the shaded area above the "Date(s) of Service." [12,14]

Considerations When Adding GSK Vaccines to Your Practice

When adding a GSK vaccine to your practice, consider the following:

  Checklist for Completing the CMS-1500 Claim Form [13]
Keep the patient's demographic and insurance information updated for accuracy.
Verify each patient's benefits before service. Use an Advance Beneficiary Notice (ABN) and Patient Financial Responsibility Agreement (PFRA) form to establish the patient's responsibility.
Verify restrictions and prior authorization requirements; get instructions for these processes.
If required by the payer, or by special circumstances, consider attaching a letter of medical necessity to your initial claim, detailing why the vaccine was chosen for a specific patient.
Re-check claims for coding accuracy.
File claims in a timely manner to comply with the insurer's time limits.
Follow up with insurers if appropriate.
Review Remittance Advice (RA) and Explanation of Benefits (EOB) from insurers for accuracy.
Prepare to appeal any denials with supportive literature.
Consider other resources to resolve denials (eg, patient's employer group and the patient).
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826034R0 October 2017

Please note that this website is provided for informational purposes only and is not intended to serve as comprehensive training on medical billing and coding. Additional training on medical coding may be required. The information on this website is believed to be accurate as of the date of publication. Users should independently verify accuracy.

Healthcare providers are responsible for making the ultimate decision on when to use a specific product based on clinical recommendations and how to bill for products and related services rendered. Consult third-party insurers' guidelines for specific information regarding the billing and reporting of services rendered.

You are encouraged to report vaccine adverse events to the US Department of Health and Human Services.
Visit to file a report, or call 1-800-822-7967.

To learn more about the
GSK Vaccines Access Program,
click here.
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