CMS-1500 for NEMT: how to fill out the claim form for transportation
NEMT paper claims go on the CMS-1500, version 02/12, filled out under the NUCC instruction manual (version 13.0, July 2025) and your payer's rules. Each trip line needs the date, a place of service code (41 in Colorado and Nebraska), the HCPCS code and modifiers, the charge, and units in trips or miles. The authorization number goes in item 23 and the billing provider in item 33.
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What the CMS-1500 is and who still takes it
The CMS-1500 is the standard paper claim form for professional services. Medicaid programs such as Colorado, Nebraska, North Dakota, and Texas accept it for NEMT. The current version is 02/12, which the Office of Management and Budget approved on June 10, 2013. The National Uniform Claim Committee (NUCC) maintains the form and publishes the instruction manual. The current manual is version 13.0, released July 2025.
Two rules sit on top of the NUCC manual:
- Your payer’s instructions win. The NUCC manual says its instructions are not specific to any payer. Every Medicaid program and broker publishes its own field rules, and those decide whether a claim pays.
- The paper form mirrors the electronic claim. The NUCC instructions line up with the 837P professional claim, version 5010A1. Everything below also applies to electronic claims. See our 837P guide for the loops and segments.
Some programs require paper. Nebraska’s fee-for-service NEMT instructions say the CMS-1500 must be used and the original mailed to the Medicaid Claims Unit in Lincoln. North Dakota accepts the CMS-1500 or an 837P. Texas encourages electronic claims but still documents paper claims for its Medical Transportation Program.
The boxes that matter for NEMT
Most of the form is patient and insurance data you copy from the authorization. The service lines in item 24 are where NEMT claims succeed or fail. The table follows the NUCC manual, with state rules from Colorado, Nebraska, and Texas where they differ.
| Item | What goes there | NEMT notes |
|---|---|---|
| 1a | Insured’s ID number | The Medicaid ID. Texas wants the 10-digit number from the MTP authorization form. Nebraska wants the 11-digit client number. |
| 2 | Patient’s name | Last name, first name, middle initial, as on the authorization. |
| 12 | Patient’s signature | Colorado accepts “Signature on File” or “SOF.” |
| 19 | Additional claim information | Colorado: enter “TRANSPORT CERT” when you have a transportation certificate or trip sheet on file. |
| 21 | ICD indicator and diagnosis | Indicator 0 for ICD-10. Colorado: R68.89. Nebraska: R69. Texas: Z753. Do not enter the decimal point. |
| 22 | Resubmission code | 7 to replace a prior claim, 8 to void it, plus the original reference number. |
| 23 | Prior authorization number | The number the payer assigned, with no hyphens or spaces. Texas requires it. Colorado marks it not required. |
| 24A | Dates of service | Colorado allows one date of service per NEMT claim and no span billing. |
| 24B | Place of service | 41 in Colorado and Nebraska. The Texas MTP handbook lists 09 for paper claims. |
| 24C | EMG | Colorado: enter N or leave blank for non-emergency trips. |
| 24D | Procedure code and modifiers | The HCPCS code plus up to four two-character modifiers, such as origin and destination. |
| 24E | Diagnosis pointer | The letter of the diagnosis in item 21, usually A. |
| 24F | Charges | Your usual and customary charge, with no dollar signs or commas. |
| 24G | Days or units | Trips for base codes, miles for mileage codes. Colorado accepts whole numbers only. |
| 24J | Rendering provider ID | The NPI of the provider who performed the service, only when it differs from item 33a. |
| 31 | Signature and date | Nebraska accepts a stamp or computer-generated signature, dated on or after the service date. |
| 32 | Service facility location | Colorado requires the name and address where the service was performed. |
| 33 and 33a | Billing provider and NPI | Name, street address, 9-digit ZIP, phone. Nebraska wants the 11-digit Medicaid provider number instead of an NPI in 33a. |
For the codes that go in item 24D, see NEMT billing codes. For the two-letter place modifiers, see origin and destination modifiers.
Example: one wheelchair van trip in Colorado
Here is how a one-way wheelchair van trip would look under Colorado’s rules. The trip is a hypothetical: a Health First Colorado member rides 12 loaded miles from home to a dialysis center.
| Line | 24A | 24B | 24C | 24D | 24E | 24G |
|---|---|---|---|---|---|---|
| 1 | Date of the trip | 41 | N | A0130 | A | 1 |
| 2 | Same date | 41 | N | S0209 | A | 12 |
Item 21 carries indicator 0 and R68.89. Item 24F on each line carries your usual and customary charge, which Colorado says cannot be more than you charge riders who are not on Medicaid. The return trip belongs on the same claim, because Colorado allows one date of service per claim. Colorado counts one unit per one-way leg on its taxi code and asks for modifier 76 when the same provider bills more than one trip for a member in a day, so confirm with HCPF how it wants a wheelchair return leg entered.
The same trip in Indiana would look different. Indiana bills mileage with A0425 and modifier U5 and appends origin and destination modifiers to both lines. Indiana also allows a round trip at the same service level on one line with two units, with all the miles on one mileage line.
Sending the claim and supporting paperwork
Keep a copy of everything you mail. Nebraska’s instructions say to retain a duplicate and mail the original form. Attachments follow payer rules too:
- Colorado accepts attachments with claims keyed into its provider web portal and requires one on any NEMT claim that needs manual pricing.
- Colorado also suspends a claim for review when the miles billed on S0215, S0209, or A0425 exceed 52, or 125 for members in designated rural counties. The claim is denied if the supporting attachment is missing or does not meet the manual’s requirements.
- North Dakota requires its trip ticket form (SFN 296) for the main NEMT codes. Newly enrolled providers must send the applicable authorization or trip ticket form with each claim during a review period.
When in doubt, ask the payer before you mail. A missing attachment turns a clean trip into a denial.
Mistakes that get paper claims returned
Paper claims fail for reasons that have nothing to do with the trip. These come straight from the NUCC manual and state instructions:
- Photocopied forms. Medicare’s manual says photocopies of the CMS-1500 are not acceptable, and its print specification calls for red OCR dropout ink.
- More than six lines. Colorado does not process a seventh line and does not accept continuation claims marked “Page 1 of 2.”
- Fractions in units. Colorado wants whole numbers in item 24G. Indiana tells providers how to round: 15.5 to 16.0 miles bills as 16, and 15.0 to 15.4 bills as 15.
- Punctuation in addresses. NUCC says to leave out commas, periods, and symbols in items 32 and 33 and to use a 9-digit ZIP code without the hyphen.
- A late or missing signature date. Nebraska requires the signature date to fall on or after the dates of service.
- Spaces or hyphens in the authorization number. NUCC says to enter the number in item 23 without either.
A claim returned for missing data is usually a rejection, not a denial, and you fix it and send it again. Our guide to NEMT claim denials covers the difference and what each reason code means.
Keeping the trip record ready
Payers can ask for proof of a trip long after it was paid, and the answer is the trip record. HealthRide’s trip log report lists each leg with scheduled and actual times, addresses, driver, vehicle, and GPS-recorded miles, and exports as a spreadsheet or print-ready PDF. When a payer asks for documentation, the record of the ride is one click away.
Frequently asked questions
- What place of service code do NEMT providers use on the CMS-1500?
- It depends on the payer. Colorado and Nebraska both tell NEMT providers to enter 41, which Colorado describes as land transportation. The Texas Medical Transportation Program handbook lists 09 for paper claims and 99 for claims entered in TexMedConnect. Use the code in your state manual or broker contract, not a guess from the national list.
- Where does the trip authorization number go on a CMS-1500?
- Item 23, Prior Authorization Number. The NUCC manual says to enter the number the payer assigned, with no hyphens or spaces. Texas's Medical Transportation Program requires the authorization number it issued. Some programs leave item 23 empty for NEMT: Colorado marks it not required.
- How do I bill mileage on the CMS-1500?
- Put the mileage code, such as S0209 for wheelchair van miles, on its own service line and enter the miles as units in item 24G. Colorado accepts whole numbers only. Indiana rounds half a mile or more up to the next whole mile. Medicare ambulance claims are the exception: they report miles to the tenth under 100 miles.
- Can I print CMS-1500 forms on my office printer?
- Only if the result meets the print specifications. Medicare's claims manual allows forms from printers or printed in-house as long as they follow NUCC specifications, and its print specification calls for red OCR dropout ink. Photocopies are not acceptable. Nebraska and Medicare both point providers to the U.S. Government Printing Office, and Nebraska also to private vendors, for printed forms.
- How many trips fit on one CMS-1500?
- Six service lines per form. Colorado will not process lines beyond six and does not accept continuation claims, so each form must be complete and totaled. Colorado also allows only one date of service per NEMT claim, so trips on different days go on separate forms.
- How do I correct a CMS-1500 claim that already paid?
- Resubmit it with a frequency code in item 22: 7 to replace the prior claim or 8 to void it, followed by the payer's original reference number for that claim. Item 22 is only for resubmissions, not original claims. Some payers add their own steps; Nebraska points providers to a separate adjustment procedure, so check the manual first.
