Special Instructions for Submitting Claims on the CMS-1500 
for Members with Medicare Coverage 
Refer to Subchapter 5, Part 7 of your MassHealth provider manual for instructions on claims 
for members with Medicare coverage. 

Important: The table below lists specific fields on the CMS-1500 that must be completed for 
claims where the member has Medicare in addition to MassHealth. In addition to completing all 
applicable fields, all TPL claims must be submitted with the appropriate Explanation of 
Medicare Benefits (EOMB) and/or other necessary TPL documentation. Providers must ensure 
that the appropriate carrier code is clearly written on each EOB. 

Scenario: MassHealth member, Rhonda Rocket, sees her provider for medical services. 
Rhonda also has Medicare and supplemental insurance coverage. The total charge for her 
claim is $100. The combined total payment by Medicare and the other insurer was $30. 
Medicare paid $5 and the other insurer paid $25. 

Field #
Field Name
TPL Required 
Information
Example
1
Unnamed
For crossover claims 
only, check 
“Medicare.”
Medicare
1a
Insured’s I.D. Number
For crossover claims 
only, enter the 
member’s Medicare 
ID number.
111111111c1
4
Insured’s Name
If the member has 
Medicare, enter the 
insured’s name in the 
following order: last 
name, first name, 
middle initial.
Last, First, Middle 
Initial
6
Patient Relationship to 
Insured
Enter an X in the 
correct box to 
indicate the patient’s 
relationship to the
insured. Only one 
box can be marked.
X  Self
10d
Reserved for Local 
Use
If submitting a 
crossover claim, 
enter the complete 
12-character
member identification 
(ID) number that is 
printed on the 
MassHealth
card.
111122223333
11
Insured’s Policy 
Group or FECA 
Number
Enter the Medicare 
policy or group 
number as it appears 
on the Medicare 
card.
XX12345
11a
Insured’s Date of 
Birth, Sex
Date of birth of the 
Medicare subscriber
01/01/1940   X F
11c
Insurance Plan or 
Program Name
Enter the seven-digit 
MassHealth TPL 
carrier code for 
Medicare Part B  
(0085000).
Medicare carrier 
code 0085000
11d
Is There Another 
Health Benefit Plan?
Check box indicating 
whether the patient 
has insurance in 
addition to 
MassHealth and 
Medicare. If this box 
is checked “yes”, 
complete Fields 9 
and 9a-9d with 
applicable 
commercial health 
plan information.
X Yes
9
Other Insured’s Name
If 11d is checked 
“yes,” enter the name 
of the subscriber, if 
different from that in 
Field 2. 
Last, First, Middle 
Initial
9a
Other Insured’s Policy 
or Group Number
If 11d is checked 
“yes,” enter the group 
or policy number for 
the commercial 
insurance plan. 
00054321
9b
Other Insured’s Date 
of Birth, Sex
If 11d is checked 
“yes,” enter the date 
of birth and gender of 
the policyholder 
noted in Field 9.
01/01/1940     X F
9d
Insurance Plan Name 
or Program Name
If 11d is checked 
“yes,” enter the 
seven-digit 
MassHealth TPL 
carrier code.
ABC Corp. carrier 
code 9991001
27
Accept Assignment? 
Yes or No
For Medicare Claims:
Enter an X in the 
appropriate box to 
indicate whether the 
provider accepts 
assignment.
X Yes
29
Amount Paid
Enter the total 
amount paid by all 
insurers other than 
MassHealth.
$30.00
Attachment
TPL Attachment
In addition to 
completing all 
applicable fields, all 
TPL claims must be 
submitted with the 
appropriate 
Explanation of 
Medicare Benefits 
(EOMB) and/or other 
necessary TPL 
documentation. 
EOB 1 – Medicare 
carrier code 0085000

EOB 2 – ABC Corp. 
carrier code 9991001