cms 1500 guidelines

Showing Patient Payments in CMS 1500 guidelines form

Most of the practices would collect copayments from the patient at the time service. Although it’s not a violation for participating providers to accept payment prior to rendering services, there are specific guidelines to follow, especially when reporting these payments.

Additionally, some providers who accept assignment have a concern that Medicare issues partial checks to beneficiaries. Such checks are generally issued because of a patient paid amount in item 29 of the CMS 1500 guidelines (02/12) claim form.

Here are a few guidelines to follow;

Medicare Part B recommends not to collect copay amounts prior to a claim being submitted to Medicare since it is difficult to predict when deductible/coinsurance amounts will be applicable (and over-collection is considered program abuse). So, it is recommended that providers not to do so until Medicare Part B payment is received.

If you believe you can accurately predict the coinsurance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. It is recommended that providers do not collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse. In addition, this practice can cause a portion of the provider’s check to be issued to beneficiaries on assigned claims. 

Do not collect money from the patient for the preventive services for which copayment and coinsurance are waived. Please refer Preventive Services covered by Medicare.

Do not show any amounts collected from patients if the service is never covered by Medicare Part B or you believe, in a particular case, the service will be denied payment. Where patient paid amounts are shown for services that are denied payment, a portion of the provider’s check may go to the beneficiary.

There is no need to show a patient paid amount in item 29 of form CMS 1500 guidelines (or electronic equivalent) when assignment is not accepted.


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