CMS-1500 Details

Version 14.8

Overview

This purpose of this article is meant to explain each box in the CMS-1500 form. The form is shown in the PDF below and the box descriptions are in the following section.

CMS-1500 Box Descriptions

The following table details the fields of the most current CMS-1500 form, FORM 1500 (02-12), and provides the path for where the respective information is found in OP14.   

CMS-1500 box
Box Descriptor
OP Path to Field Contents
Additional Information
Box 1
Claim Filing Type
Add/Edit Charges window > Other Items tab > Item 1 field. This is pre-populated based on the claim type indicated in the payer setup (Utilities > Manage Practice > Insurance Payers > Double-click payer > Claims/Routing tab > Claim Type).

Box 1a
Insured's ID Number
Account or Register > Insurance tab > Subscriber ID field

Box 2
Patient's Name
Register > Patient tab > Last name, First Name, Middle Initial fields

Box 3
Patient's Date of Birth
Register > Patient tab > Birthdate field

Box 4
Insured's Name
Account or Register > Insurance tab > Subscriber Last name, First name, Middle Initial fields

Box 5
Patient's Address
Register > Patient tab > Primary Address Fields, Primary phone field

Box 6
Patient Relationship to Insured
Account or Register > Insurance tab > Patient rel to Subscriber field

Box 7
Insured's Address
Account or Register > Insurance tab > Address/Employer tab
If this is an insurance that does not validate, OP will pull the patient's address.
Box 8
Reserved for NUCC Use
This item currently does not print on the CMS-1500 form.

Box 9
Other Insured's Name
Account or Register > Insurance tab > Secondary Insurance record > Subscriber Last name, First name, Middle Initial fields
This will only populate if a secondary insurance is ranked.
Box 9a
Other Insured's Policy or Group Number
Account or Register > Insurance tab > Secondary Insurance record > Subscriber ID field
This will only populate if a secondary insurance is ranked.
Box 9b
Reserved for NUCC Use
This item currently does not print on the CMS-1500 form.

Box 9c
Reserved for NUCC Use
This item currently does not print on the CMS-1500 form.

Box 9d
Insurance Plan Name or Program Name
Account or Register > Insurance tab > Secondary Insurance record > Insurance Carrier field
This will only populate if a secondary insurance is ranked.
Box 10 a-c
Is Patient's Condition Related To
Add/Edit Charges window > Other Items tab > Item 10a, Item 10b, Item 10c fields

Box 10d
Claim Codes (Designated by NUCC)
This item currently does not print on the CMS-1500 form.

Box 11
Insured's Policy Group or FECA Number
Account or Register > Insurance tab >  Group number field

Box 11a
Insured's Date of Birth, Sex
Account or Register > Insurance tab > Sex/birth date field

Box 11b
Other Claim ID (Designated by NUCC)
This item currently does not print on the CMS-1500 form.

Box 11c
Insurance Plan Name or Program Name
Account or Register > Insurance tab > Primary Insurance record > Insurance Carrier field

Box 11d
Is there another Health Plan Benefit?
'Yes' will be marked if a secondary insurance is added and ranked in OP.  'No' will be marked if there is no secondary insurance ranked in OP.

Box 12
Patient or Authorized Person's Signature
Account or Register > Insurance tab > Patient signature on file checkbox

Box 13
Insured's or Authorized Person's Signature
Account or Register > Insurance tab > Patient signature on file checkbox

Box 14
Date of Current Illness, Injury or Pregnancy (LMP)
Add/Edit Charges window > Other Items tab > Item 14 field

Box 15
Other Date
This item currently does not print on the CMS-1500 form

Box 16
Dates Patient Unable to Work in Current Occupation
Add/Edit Charges window > Other Items tab > Item 16 field

Box 17
Name of Referring Provider or Other Source
Add/Edit Charges window > Other Items tab > Item 17 field (Note: there are two Item 17 fields, only one may be populated for Print. If both are populated, the Referring Provider field will super-cede). The Address book button in this field can be used to choose the provider's info, as long as that provider has an entry in the Address book.
The information in this box can be auto-populated by setting a System Preference to auto-populate PCP as Referring Provider.
Box 17a
Referring, Order, or Supervising Provider Other ID #
Address Book > Staff/Provider tab > Line 17a field
The information in this box can be auto-populated in conjunction with box 17 setting a System Preference to auto-populate PCP as Referring Provider.
Box 17b
Referring Provider or Other Source NPI
Add/Edit Charges window > Other Items tab > Item 17b field (Note: there are two Item 17b fields, only one may be populated for Print)
This will also pull from the Address Book entry of the Referring or Ordering Dr.
Box 18
Hospitalization Dates Related to Current Services
Add/Edit Charges window > Basic Info tab > Hospital dates from and to fields

Box 19
Additional Claim Information (Designated by NUCC)
This item currently does not print on the CMS-1500 form

Box 20
Outside Lab?, $ Charges
Add/Edit Charges window > Other Items tab > Item 20 field

Box 21
Diagnosis or Nature of Illness or Injury, ICD Ind.
Add/Edit Charges window > Basic Info tab > Diagnosis Codes

Box 22
Resubmission Code, Original Ref. No.
Add/Edit Charges window > Other Items tab > Item 22 fields (including Original reference # or Transaction # field)

Box 23
Prior Authorization Number
Add/Edit Charges window > Other Items tab > Item 23: Referral # field
If it is required for a CLIA ID to be present on a CMS-1500 form, it must be entered here.
Box 24a
Date(s) of Service
Unshaded area: Add/Edit Charges window > Basic Info tab > Service date(s) from and to fields
Shaded area: NDC # as entered in Charges area > NDC field

Box 24b
Place of Service
Add/Edit Charges window > Basic Info tab > Place of service field

Box 24c
EMG
Add/Edit Charges window > Basic Info tab > Charges area> EMG column
You may have to add the EMG column by using the 'Visible Columns' button.
Box 24d
CPT/HCPCS, Modifier
Add/Edit Charges window > Basic Info tab > Charges area > CPT and Mod field(s)

Box 24e
Diagnosis Pointer
Add/Edit Charges window > Basic Info tab > Charges area > DX field(s) (DX1, DX2, DX3 etc.)
These are listed as A,B,C etc. and correspond with the Diagnosis Code box entries in Box 21.
Box 24f
$ Charges
Add/Edit Charges window > Basic Info tab > Charges area > Charge field(s)
The Charge field equals the Unit Charge x Unit per CPT code line.
Box 24g
Days or Units
Add/Edit Charges window > Basic Info tab > Charges area > Units field(s)

Box 24h
EPSDT Family Plan
Add/Edit Charges window > Basic Info tab > Charges area > EPSDT field(s)

Box 24i
ID Qual.
Utilities > Manage Practice > Insurance Payers > Select Insurance >  Insurance Carrier Provider Information > ID Type

Box 24j
Rendering Provider ID #
Shaded area: Utilities > Manage Practice > Insurance Payers > Select Insurance >  Insurance Carrier Provider Information > Line 24j field
Unshaded area: Utilities > Manage Practice > Staff/Provider Directory > Provider Info tab > Provider NPID field (for each provider)

Box 25
Federal Tax ID Number
Utilities > Manage Practice > Staff/Provider Directory > Provider Info tab > Federal Tax ID field

Box 26
Patient's Account No.
Patient Number as assigned in OP14

Box 27
Accept Assignment
Account or Register > Insurance tab > Provider accepts assignment checkbox

Box 28
Total Charge
Total Charges indicated in Box 24f

Box 29
Amount Paid
Total of Payments + Adjustments posted to claim

Box 30
Rsvd for NUCC Use
This item currently does not print on the CMS-1500 form.

Box 31
Signature of Physician or Supplier
Utilities > Manage Practice > Staff/Provider Directory > Provider Info tab > Signature Name field

Box 32
Service Facility Location Information
Utilities > Manage Practice > Hospital Facilities
If System Preference is selected to auto-populate service location when POS=11, Box 32 will prefill with office location.
Box 32a
Service Facility Location NPI #
Utilities > Manage Practice > Hospital Facilities > Facility NPI/Tax ID

Box 32b
Other ID #
Utilities > Manage Practice > Hospital Facilities > Facility ID

Box 33
Billing Provider Info & Ph #
Utilities > Manage Practice > Staff/Provider Directory > Practice Info tab > Billing/Pay-To Information > Billing name and address fields

Box 33a
Billing Provider NPI #
Utilities > Manage Practice > Staff/Provider Directory > Practice Info tab > Practice NPI field

Box 33b
Billing Provider Other ID #
Utilities > Manage Practice > Insurance Payers > Select Insurance >  Insurance Carrier Provider Information > Line 33b field

Additional Resource

You can view the full NUCC (National Uniform Claim Committee) CMS-1500 form Manual by clicking here.