Understanding a CMS 1500 Form

When you're ready to file your first claim with Doulado, simply click here to access an article that will guide you through the process. Below, you'll find an overview of the boxes on a CMS 1500 form, which is a standard billing form used by healthcare providers, including doulas, to submit claims for services to insurance payers. This form provides detailed information about the services provided, the patient, and the provider.

Box # Entry Details
1 Select the Payer Type
1a  Client Member ID #
2 Client Name
3 Client's Date of Birth
4 Insured Name
5 Client Address
6 Relationship to Insured
7 Insured Address
8 Not for Doula Use
9

Other Insurance Coverage

Subscriber
9a Policy # of Other insurance
9b Not for Doula Use
9c Not for Doula Use
9d Name of Other Insurance Carrier
10 a-c Not for Doula Use
11 a-d Not for Doula Use
12 Doulado Will Auto Fill
13 Doulado Will Auto Fill
14-16 Not for Doula Use
17 Referring Physician Info (if required)
18 Enter Hospitalization Dates (When billing for births)
19 Not for Doula Use
20 Not for Doula Use
21 a-l Appropriate ICD-10-CM Diagnosis Code
22 Doulado Will Auto Fill (when needed)
23 Enter Authorization # (when needed)
24a

Enter the Dates of the Service

(Service description or notes can be added in the blank red space above the service dates/codes if needed)
24b Code for Place of Service
24c Not for Doula Use
24d All Modifiers your Payer Requires
24e The Pointer your Payer Requires
24f Charges for Your Covered Services
24g Units you are Billing for
24h Not for Doula Use
24i Not for Doula Use
24j Your NPI
25 Your EIN or SSN (whatever you use for tax purposes)
26 Doulado will Auto Fill
27 If your payer uses Govt. funds, you will select Yes
28 Total Charges for All Services x Units
29 Doulado will Auto Fill
30 Not for Doula Use
31 Doulado will Auto Fill
32 & 32a

Only need to complete if service is

rendered at a hospital 
33 & 33a Your Name, Address, Phone # and NPI (Individual or Business depending on how you are credentialed (Doulado will auto fill if saved in business info)

Be sure to check with your specific payer to confirm their claim filing guidelines, as requirements can vary. Verifying these details ahead of time will help ensure your submissions are accurate, compliant, and processed smoothly.