Special Instructions for Submitting Claims on the CMS-1500 
for Members with Commercial Insurance 
Providers submitting paper claims must refer to the MassHealth Billing Guide for the 
CMS-1500.  

Important: The table below lists specific fields on the CMS-1500 that must be completed for 
all MassHealth claims where the member has commercial insurance in addition to MassHealth. 
In addition to completing all applicable fields, all claims for members with other insurance must 
be submitted with the appropriate explanation of benefits (EOB) 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 insurance coverage through both Blue Cross/Blue Shield (BC/BS) and ABC 
Corp. The total charge for her claim is $100.00. A combined total of $25.00 has been paid by 
other insurance carriers (BC/BS and ABC Corp.). 

Field #
Field Name
TPL Required 
Information
Example
1
Unnamed
Check box marked 
“Medicaid.”
Medicaid
1a
Insured’s ID Number
12-digit MassHealth 
member ID
111122223333
4
Insured’s name
If the member has 
other insurance, and 
if the subscriber’s 
name is different 
from that in Field 2, 
enter the 
subscriber’s name. 
Last, First, Middle 
Initial
6
Patient Relationship to Insured
Relationship of the 
patient to the insured
X  Self
11
Insured’s Policy Group or FECA 
Number
Enter the policy or 
group number of the 
first commercial 
insurance resource 
as it appears on the 
member’s insurance 
card.
For BC/BS, use 
MM54321
11a
Insured’s Date of Birth, Sex
Date of birth of the 
primary commercial 
insurance subscriber
01/01/1940    X F
11c
Insurance Plan or Program Name
Enter the seven-digit 
MassHealth TPL 
carrier code for the 
commercial 
insurance. 
BC/BS carrier code 
002700 (primary 
insurance carrier)
11d
Is There Another Health Benefit 
Plan?
Check box indicating 
whether the patient 
has insurance in 
addition to 
MassHealth and the 
commercial 
insurance identified 
in Fields 11-11c.  If 
this box is checked 
“yes,” complete 
Fields 9 and 9a-9d 
with information 
applicable to the 
other commercial 
health plan.
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. 
For ABC Corp., use 
987654321A
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 
(Other insurance 
carrier)
27
Accept Assignment? Yes or No
For Other Insurance  
Non-Crossover 
Claims:
Leave this field 
blank.
[Blank]
29
Amount Paid
Enter the total 
amount paid by all 
insurers other than 
MassHealth.
$25.00
Attachment
TPL Attachment
In addition to 
completing all 
applicable fields, all 
claims for members 
with other insurance 
must be submitted 
with the appropriate 
explanation of 
benefits (EOB) or 
other necessary TPL 
documentation. 
Providers must 
ensure that the 
appropriate carrier 
code is clearly 
written on each EOB.
EOB 1 –  BC/BS  
carrier code 
0027000

EOB 2 – ABC Corp. 
carrier code 
9991001