Superbill vs CMS-1500
February 27, 2023
Anyone who works with medical insurance in a private practice has probably run into a pair of similar forms: the superbill vs. CMS-1500. The main difference is that while both act as a health insurance claim form, CMS-1500s are used for in-network billing, and superbills are used for out-of-network billing.
In this post, we will explain what a CMS-1500 claim form is used for, then cover everything you might need for any type of health insurance claim form: CMS-1500 form orders, CMS-1500 billing forms, superbills, HCFA-1500 forms, and UB-04s. We will also show you a sample CMS-1500 form filled out, so you can see how all the parts fit together. If this all seems like alphabet soup right now, don’t worry—we’ll take things step-by-step.
The difference between superbills and CMS-1500s
The simplest way to decide between a superbill vs. CMS-1500 is to ask yourself how you will be paid for your services. Will your payments come from an insurance network, or will your patients be paying out of pocket? The simple difference is: you will use CMS-1500 forms for in-network patients and superbills for out-of-network (OON) patients.
For a deeper understanding, it helps to know the difference between in-network and out-of-network in detail. Assuming you have that down, let’s move on to the specifics of the forms themselves.
What are superbills?
Superbills are essentially itemized receipts for healthcare services rendered by an out-of-network provider. You will present your patients with a superbill after they’ve paid out of pocket, if you are a provider who does not accept the patient’s insurance plan. The patient can then submit their superbills to their insurance for possible reimbursement. If they have insurance that covers your OON services, they will be reimbursed for a portion of the costs based on their plan.
Superbills have looser formatting requirements than CMS-1500s. While CMS-1500s have to come in a specific form with a hue of red ink that not all printers can recreate (meaning you have to place CMS-1500 form orders), superbills come in multiple shapes and sizes, and providers can create their own. That being said, there are some specific identifiers that must be in every superbill, like CPT and ICD-10 Codes and NPI numbers.
For details on which details are needed in a superbill, see our post, What is a superbill? There you will find a thorough guide to superbills with breakdowns of sample superbills, explanations, a quiz, and a free printable superbill template for providers or medical coders tasked with creating and filling superbills.
What is the CMS-1500 form?
There is a decent chance you have already gone straight to the source to read about CMS-1500s on CMS.gov. If you haven’t, we don’t really recommend it. Usually, the CMS website is very informative. But in this case they give a wordy and highly technical explanation of CMS-1500 forms, complete with a bonafide alphabet soup of acronyms. The CMS site even says they are actually not involved in the creation or maintenance of CMS-1500 forms. So why is it called a CMS-1500 form? It’s all a bit confusing.
Rather than bombard you with acronyms, we are going to do our best to explain CMS-1500 forms simply. The CMS-1500 health insurance claim form is used by non-institutional healthcare providers to file in-network insurance claims. “Non-institutional” in this case means private practices, as opposed to institutions like hospitals. Like a superbill, a CMS-1500 is a receipt of medical services rendered, but it is not given to patients. Instead, providers submit CMS-1500 forms directly to insurers.
The CMS-1500 is also known as the Professional Paper Claim Form. Not only is it used in private insurance claims, but also with a number of government-sponsored insurance plans including Medicare, Medicaid, and Tricare. CMS-1500 forms are made and maintained by the National Union Claim Committee (NUCC). The NUCC updates their CMS-1500 claims guidelines annually, and you find their most recent manual here.
What is the CMS-1500 claim form used for?
The first thing to note is that you will only use a CMS-1500 form if you maintain an insurance-based practice. Out-of-network and non-insurance-based practices will use superbills instead. Deciding whether or not you want to join an insurance panel is a big step for any private practitioner. In general, insurance-based practices have to jump through more hoops and sacrifice some flexibility, and the penalties tend to be higher if you make mistakes. So if you do accept insurance, handle your CMS-1500 forms with care.
For insurance-based providers, CMS-1500 forms ensure you get paid. That’s why it’s important to stay on top of them. Unlike superbills, which are ultimately the patient’s responsibility to fill out and submit, CMS-1500 forms must be completed and submitted to insurance by the provider’s office. Once your claim is processed, the insurance company will pay you in the form of a reimbursement. Assuming the patient has met their deductible, they will only owe a copayment.
If a CMS-1500 claim is denied, providers can correct and resubmit the claim. If resubmitting fails, the patient is held responsible for the cost of the service and may incur debt.
Sample CMS-1500 form
Below we will look at a sample CMS-1500 form filled out with all the necessary information for reimbursement. First, we would like to note that if you are submitting a CMS-1500 by mail, it must be printed with a specific red ink. You can buy these forms at office supply stores like Staples or Office Depot. We do NOT advise printing your own forms, since it is unlikely that your printer has the correct OCR hue of red ink for CMS-1500 forms, and your claims can be denied for that reason alone.
If you’re fed up with placing CMS-1500 form orders, we have good news. These days, many providers and insurers have made the switch to electronic forms. Electronic CMS-1500 forms generally are faster and more accessible than printed ones, so we recommend asking the insurance company you work with if they accept electronic submissions.
Notice the hue of red ink the form uses. Copies of this form are not valid for claims submissions. Here is the NUCC’s note on the subject.
“The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be printed from our software, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the OCR color of the form. The majority of paper claims sent to carriers and DMERCs are scanned using Optical Character Recognition (OCR) technology. This scanning technology allows for the data contents contained on the form to be read while the actual form fields, headings, and lines remain invisible to the scanner.”
Now let’s look at the individual parts of the CMS-1500 form.
Sample CMS-1500 form breakdown
There are 33 boxes in a CMS-1500 form. You must fill all applicable boxes for the claim to be processed. Let’s look at the most important boxes in more detail now.
Insurance Information: Boxes 1, 1A, and 11
Box 1: The name of the patient’s insurance payer goes in Box 1. For instance, if you have filed a Medicare claim, check the Medicare checkbox. If you have filed a claim with a private insurer, check Other.
Box 1A: Insured’s ID Number
Box 11: Insured’s group number
Patient Identification: Boxes 2-7
Box 2: Enter the patient’s name as it is written on their insurance card.
Box 3: Write the patient’s 8-digit birth date (MM/DD/YYYY) and sex here.
Box 4 (if applicable): You will only need to fill Box 4 if you are billing for an infant using the mother’s ID. If so, enter the insured person’s ID number.
Box 5: Patient’s address and telephone number.
Box 6: The patient’s relationship with the insured person.
Box 7: Insured person’s address—only applicable if different from Box 5.
Diagnosis Codes: Box 21
Box 21: Here, enter the diagnosis code(s) and the primary reason for providing the services. You must use the proper ICD-10 codes, or the claim will be rejected. For help with CPT and ICD-10, read our post on Medical Coding Best Practices.
Date of Service: Box 24A
Box 24A: This box indicates the date of each service rendered. You can enter a maximum of 6 services in one CMS-1500 claim form.
CPT Codes: Boxes 24D and 24G
Box 24D: Enter the appropriate CPT codes for the procedure(s) in Box 24D. When applicable, modifiers are listed to the right of the primary code under the column marked “modifier”. If the item is a medical supply, enter the two-digit manufacturer code in the modifier area after the five-digit medical supply code.
Box 24G: Box 24G indicates the duration or “units” of the medical service. Enter the number of medical visits, units of procedure time, number of 45-minute therapy sessions, etc. The numeral ‘1’ must be entered if only one operation is conducted. Avoid decimal points and leading zeros. Do not leave blank. Your unit(s) should be at least 1.
Charges: Box 24F
Box 24F: Input the total billed amount for each service line. You must also include the applicable state and country sales tax if the item is a taxable medical supply.
Provider Information: Box 24J
Box 24J: This box identifies the provider who rendered the service. Enter their NPI number in the field’s unshaded location. The Rendering Provider is the individual or firm (laboratory or another facility) that made or managed the treatment. If a replacement provider was used, enter the details of that provider instead.
Location Details: Boxes 24B, 32
Box 24B: Enter the code for the location where the service was rendered. Note that you must enter the appropriate two-digit Place of Service code.
Box 32: Name and address of the facility where services were rendered.
Billing Provider Details: Boxes 33, 33A, and 33B
Box 33: Enter the Billing Provider’s name, address, ZIP code, and telephone number. Enter the details in three lines as shown below:
1st line – Name
2nd line – Address
3rd line – City, State, and ZIP code
Box 33A: Billing provider’s NPI number.
Box 33B: Billing provider’s ID qualifier and PIN.
Other Required Boxes and Fields
Box 11D: Is a secondary health benefit plan being used? If so, check the ‘YES’ box and include those plan details in boxes 9, 9a, and 9d.
Box 14: Date of current illness, injury, or pregnancy (LMP = last menstrual period).
Box 24E: The Diagnosis Code from Box 21 also goes here.
Box 25: Provider’s federal tax ID number, either Social Security Number or EIN.
Box 28: The total bill amount for all services in dollars.
Box 31: Sign and date here. Stamps and initials are not accepted.
Note: The boxes we did not cover in this post are “not required” and “if applicable” fields. You can fill them as you see fit.
Other examples of health insurance claim forms
Hopefully, this post has cleared up the difference between superbills and CMS-1500 forms, but you may still have a few doubts about related forms. Providers working with CMS-1500s and superbills often have questions about HCFA-1500 and UB-04 forms as well. We’ll address those now.
What is a HCFA-1500 form?
A HCFA-1500 form is the same thing as a CMS-1500 form. HCFA stands for Health Care Financing Administration, the agency that handles the funding for the Medicare, Medicaid and CHIP programs. The terms CMS-1500 and HCFA-1500 are used interchangeably, so everything you learned about CMS-1500s applies here.
What is the difference between the CMS-1500 and UB-04 forms?
As we mentioned earlier in the post, the CMS-1500 form is used by non-institutional healthcare providers to file in-network claims. The UB-04 form, on the other hand, is used by institutional healthcare entities like hospitals, long-term nursing, or outpatient facilities. A UB-04 form could be used for services like radiology, laboratory work, or surgery. It is also called a CMS-1450 form.
CMS-1500 form orders
CMS.gov gives the following information about ordering paper CMS-1500 forms: “In order to purchase claim forms, you should contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores. Each of the vendors above sells the CMS-1500 claim form in its various configurations (single part, multi-part, continuous feed, laser, etc).” However, it will be a lot easier on you and/or your billing department if you file your forms electronically.
Now, we hope you have a better understanding of the superbill vs. CMS-1500 vs. UB-04 discussion. Come back to this post anytime you need to see the various parts of a CMS-1500 form laid out. For a detailed breakdown of superbills with a template you can download, look at What is a Superbill?
Support for private practices with SuperBill
Running a private practice takes a great deal of attention. But accepting insurance does not have to mean accepting a bigger workload. SuperBill can help with all your out-of-network billing needs. Our out-of-network insurance billing system is swift and accurate. For lightning-quick benefits checks, claims-filing, and expert customer service, try SuperBill for insurance today.
Stay tuned for an upcoming post examining the process of insurance credentialing, where we will explore what it takes to join an insurance panel and weigh the pros and cons of accepting insurance at your private practice. In the meantime, click the Get Started button to see how SuperBill can save you time and money now!