Medicare Claims Processing Manual

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Medicare Claims Processing Manual Chapter 26 - Comple ting and Proce ssing form CMS-1500 Data Set Table of Conte nts (Rev. 3881, 10-13-17) Transmittals for Chapter 26 10 - Health Insurance claim form CMS-1500 - Claims That Are Incomplete or Contain Invalid Information - Items 1-11 - P atient and Insured Information - Items 11a - 13 - P atient and Insured Information - Items 14-33 - P rovider of Service or Supplier Information - Place of Service Codes (P OS) and Definitions - A/B Medicare Administrative Contractor (MAC) (B) Instructions for Place of Service (POS) Codes - Type of Service (TOS)

Form version 02/12: Leave blank. Item 9 - Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank.

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