Version 14.19
Overview
This article explains the Fields in the CMS-1500 form. The Form is shown in the PDF below and the Field descriptions are in the following section.
CMS-1500 Field 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 OP.
CMS-1500 Field | Field Descriptor | OP Path to Field Contents | Additional Information |
| Field 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 (Billing tab > Payers > select payer > Claims/Routing tab > Claim Type field). | |
| Field 1a | Insured's ID Number | Patient Chart button > Insurance > Edit Insurance Record tab > Subscriber ID field | |
| Field 2 | Patient's Name | Patient Chart button > Basic Information > Last name, First Name, Middle Initial fields. | |
| Field 3 | Patient's Date of Birth | Patient Chart button > Basic Information > Birth date field | |
| Field 4 | Insured's Name | Patient Chart button > Insurance > Edit Insurance Record tab > Subscriber Last name, First name, Middle Initial fields | |
| Field 5 | Patient's Address | Patient Chart button > Basic Information > Primary Address fields, and Primary phone field | |
| Field 6 | Patient Relationship to Insured | Patient Chart button > Insurance > Edit Insurance Record tab > Patient rel to Subscriber field | |
| Field 7 | Insured's Address | Patient Chart button > Insurance > Address/Employer tab | If this is an insurance that does not validate, OP will pull the patient's address. |
| Field 8 | Reserved for NUCC Use | This item currently does not print on the CMS-1500 form. | |
| Field 9 | Other Insured's Name | Patient Chart button > Insurance > select Secondary Insurance Record > Edit Insurance Record tab > Subscriber Last name, First name, Middle Initial fields | This will only populate if a secondary insurance is ranked. |
| Field 9a | Other Insured's Policy or Group Number | Patient Chart button > Insurance > select Secondary Insurance Record > Edit Insurance Record tab > Subscriber ID field | This will only populate if a secondary insurance is ranked. |
| Field 9b | Reserved for NUCC Use | This item currently does not print on the CMS-1500 form. | |
| Field 9c | Reserved for NUCC Use | This item currently does not print on the CMS-1500 form. | |
| Field 9d | Insurance Plan Name or Program Name | Patient Chart button > Insurance > Edit Insurance Record tab > select Secondary Insurance record > Insurance Carrier field | This will only populate if a secondary insurance is ranked. |
| Field 10 a-c | Is Patient's Condition Related To | Add/Edit Charges window > Other Items tab > Item 10a, Item 10b, Item 10c fields | |
| Field 10d | Claim Codes (Designated by NUCC) | This item currently does not print on the CMS-1500 form. | |
| Field 11 | Insured's Policy Group or FECA Number | Patient Chart button > Insurance > Edit Insurance Record tab > Group number field | |
| Field 11a | Insured's Date of Birth, Sex | Patient Chart button > Insurance > Edit Insurance Record tab > Sex/birth date field | |
| Field 11b | Other Claim ID (Designated by NUCC) | This item currently does not print on the CMS-1500 form. | |
| Field 11c | Insurance Plan Name or Program Name | Patient Chart button > Insurance > Edit Insurance Record tab >Primary Insurance record > Insurance Carrier field | |
| Field 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. | |
| Field 12 | Patient or Authorized Person's Signature | Patient Chart button > Insurance > Edit Insurance Record tab > Patient signature on file checkbox | |
| Field 13 | Insured's or Authorized Person's Signature | Patient Chart button > Insurance > Edit Insurance Record tab > Patient signature on file checkbox | |
| Field 14 | Date of Current Illness, Injury or Pregnancy (LMP) | Add/Edit Charges window > Other Items tab > Item 14 field | |
| Field 15 | Other Date | This item currently does not print on the CMS-1500 form | |
| Field 16 | Dates Patient Unable to Work in Current Occupation | Add/Edit Charges window > Other Items tab > Item 16 field | |
| Field 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 Global Preference to auto-populate PCP as Referring Provider. |
| Field 17a | Referring, Order, or Supervising Provider Other ID # | Clinical OR Practice Management tab > Address Book button > Staff/Provider tab > Line 17a field | The information in this box can be auto-populated in conjunction with box 17 setting a Global Preferences to auto-populate PCP as Referring Provider. |
| Field 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 Provider. |
| Field 18 | Hospitalization Dates Related to Current Services | Add/Edit Charges window > Basic Info tab > Hospital dates from and to fields | |
| Field 19 | Additional Claim Information (Designated by NUCC) | This item currently does not print on the CMS-1500 form | |
| Field 20 | Outside Lab?, $ Charges | Add/Edit Charges window > Other Items tab > Item 20 field | |
| Field 21 | Diagnosis or Nature of Illness or Injury, ICD Ind. | Add/Edit Charges window > Basic Information tab > Diagnosis Codes | |
| Field 22 | Resubmission Code, Original Ref. No. | Add/Edit Charges window > Other Items tab > Item 22 fields (including Original reference # or Transaction # field) | |
| Field 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. |
| Field 24a | Date(s) of Service | Unshaded area: Add/Edit Charges window > Basic Information tab > Service date(s) from and to fields Shaded area: NDC # as entered in Charges area > NDC field | |
| Field 24b | Place of Service | Add/Edit Charges window > Basic Information tab > Place of service field | |
| Field 24c | EMG | Add/Edit Charges window > Basic Information tab > Charges area> EMG column | You may have to add the EMG column by using the 'Visible Columns' button. |
| Field 24d | CPT/HCPCS, Modifier | Add/Edit Charges window > Basic Information tab > Charges area > CPT and Mod field(s) | |
| Field 24e | Diagnosis Pointer | Add/Edit Charges window > Basic Information 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. |
| Field 24f | $ Charges | Add/Edit Charges window > Basic Information tab > Charges area > Charge field(s) | The Charge field equals the Unit Charge x Unit per CPT code line. |
| Field 24g | Days or Units | Add/Edit Charges window > Basic Information tab > Charges area > Units field(s) | |
| Field 24h | EPSDT Family Plan | Add/Edit Charges window > Basic Information tab > Charges area > EPSDT field(s) | |
| Field 24i | ID Qual. | Billing tab > Payers button > click + in the Insurance field > select Insurance Carrier Provider > ID Type | |
| Field 24j | Rendering Provider ID # | Shaded area: Billing tab > Payers button > click + in the Insurance field > select Insurance Carrier Provider > Line 24j field Unshaded area: Practice Management tab > Staff/Providers button > Provider Info tab > select provider > Provider NPID field | |
| Field 25 | Federal Tax ID Number | Practice Management tab > Staff/Providers button > Provider Info tab > select provider > Federal Tax ID field | |
| Field 26 | Patient's Account No. | Patient Number as assigned in OP | |
| Field 27 | Accept Assignment | Patient Chart button > Insurance > Edit Insurance Record tab > Provider accepts assignment checkbox | |
| Field 28 | Total Charge | Total Charges indicated in Box 24f | |
| Field 29 | Amount Paid | Total of Payments + Adjustments posted to claim | |
| Field 30 | Rsvd for NUCC Use | This item currently does not print on the CMS-1500 form. | |
| Field 31 | Signature of Physician or Supplier | Practice Management tab > Staff/Providers button > Provider Info tab > select provider > Signature Name field | |
| Field 32 | Service Facility Location Information | Billing tab > Hospitals button | If Global Preference is selected to auto-populate service location when POS=11, Box 32 will prefill with office location. |
| Field 32a | Service Facility Location NPI # | Billing tab > Hospitals button > Facility NPI/Tax ID | |
| Field 32b | Other ID # | Billing tab > Hospitals button > Facility ID | |
| Field 33 | Billing Provider Info & Ph # | Practice Management tab > Staff/Providers button > Practice Info tab > select provider > Billing name and address fields | |
| Field 33a | Billing Provider NPI # | Practice Management tab > Staff/Providers button > Practice Info tab > select provider > Practice NPI field | |
| Field 33b | Billing Provider Other ID # | Billing tab > Payers button > click + in the Insurance field > select Insurance Carrier Provider > Line 33b field |
Additional Resource
You can view the full NUCC (National Uniform Claim Committee) CMS-1500 form Manual by clicking here.
Version 14.10
Overview
This article explains each Field in the CMS-1500 form. The form is shown in the PDF below and the Field descriptions are in the following section.
CMS-1500 Field 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 Field | Field Descriptor | OP Path to Field Contents | Additional Information |
| Field 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). | |
| Field 1a | Insured's ID Number | Account or Register > Insurance tab > Subscriber ID field | |
| Field 2 | Patient's Name | Register > Patient tab > Last name, First Name, Middle Initial fields | |
| Field 3 | Patient's Date of Birth | Register > Patient tab > Birthdate field | |
| Field 4 | Insured's Name | Account or Register > Insurance tab > Subscriber Last name, First name, Middle Initial fields | |
| Field 5 | Patient's Address | Register > Patient tab > Primary Address Fields, Primary phone field | |
| Field 6 | Patient Relationship to Insured | Account or Register > Insurance tab > Patient rel to Subscriber field | |
| Field 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. |
| Field 8 | Reserved for NUCC Use | This item currently does not print on the CMS-1500 form. | |
| Field 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. |
| Field 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. |
| Field 9b | Reserved for NUCC Use | This item currently does not print on the CMS-1500 form. | |
| Field 9c | Reserved for NUCC Use | This item currently does not print on the CMS-1500 form. | |
| Field 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. |
| Field 10 a-c | Is Patient's Condition Related To | Add/Edit Charges window > Other Items tab > Item 10a, Item 10b, Item 10c fields | |
| Field 10d | Claim Codes (Designated by NUCC) | This item currently does not print on the CMS-1500 form. | |
| Field 11 | Insured's Policy Group or FECA Number | Account or Register > Insurance tab > Group number field | |
| Field 11a | Insured's Date of Birth, Sex | Account or Register > Insurance tab > Sex/birth date field | |
| Field 11b | Other Claim ID (Designated by NUCC) | This item currently does not print on the CMS-1500 form. | |
| Field 11c | Insurance Plan Name or Program Name | Account or Register > Insurance tab > Primary Insurance record > Insurance Carrier field | |
| Field 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. | |
| Field 12 | Patient or Authorized Person's Signature | Account or Register > Insurance tab > Patient signature on file checkbox | |
| Field 13 | Insured's or Authorized Person's Signature | Account or Register > Insurance tab > Patient signature on file checkbox | |
| Field 14 | Date of Current Illness, Injury or Pregnancy (LMP) | Add/Edit Charges window > Other Items tab > Item 14 field | |
| Field 15 | Other Date | This item currently does not print on the CMS-1500 form | |
| Field 16 | Dates Patient Unable to Work in Current Occupation | Add/Edit Charges window > Other Items tab > Item 16 field | |
| Field 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. |
| Field 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. |
| Field 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. |
| Field 18 | Hospitalization Dates Related to Current Services | Add/Edit Charges window > Basic Info tab > Hospital dates from and to fields | |
| Field 19 | Additional Claim Information (Designated by NUCC) | This item currently does not print on the CMS-1500 form | |
| Field 20 | Outside Lab?, $ Charges | Add/Edit Charges window > Other Items tab > Item 20 field | |
| Field 21 | Diagnosis or Nature of Illness or Injury, ICD Ind. | Add/Edit Charges window > Basic Info tab > Diagnosis Codes | |
| Field 22 | Resubmission Code, Original Ref. No. | Add/Edit Charges window > Other Items tab > Item 22 fields (including Original reference # or Transaction # field) | |
| Field 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. |
| Field 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 | |
| Field 24b | Place of Service | Add/Edit Charges window > Basic Info tab > Place of service field | |
| Field 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. |
| Field 24d | CPT/HCPCS, Modifier | Add/Edit Charges window > Basic Info tab > Charges area > CPT and Mod field(s) | |
| Field 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. |
| Field 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. |
| Field 24g | Days or Units | Add/Edit Charges window > Basic Info tab > Charges area > Units field(s) | |
| Field 24h | EPSDT Family Plan | Add/Edit Charges window > Basic Info tab > Charges area > EPSDT field(s) | |
| Field 24i | ID Qual. | Utilities > Manage Practice > Insurance Payers > Select Insurance > Insurance Carrier Provider Information > ID Type | |
| Field 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) | |
| Field 25 | Federal Tax ID Number | Utilities > Manage Practice > Staff/Provider Directory > Provider Info tab > Federal Tax ID field | |
| Field 26 | Patient's Account No. | Patient Number as assigned in OP14 | |
| Field 27 | Accept Assignment | Account or Register > Insurance tab > Provider accepts assignment checkbox | |
| Field 28 | Total Charge | Total Charges indicated in Box 24f | |
| Field 29 | Amount Paid | Total of Payments + Adjustments posted to claim | |
| Field 30 | Rsvd for NUCC Use | This item currently does not print on the CMS-1500 form. | |
| Field 31 | Signature of Physician or Supplier | Utilities > Manage Practice > Staff/Provider Directory > Provider Info tab > Signature Name field | |
| Field 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. |
| Field 32a | Service Facility Location NPI # | Utilities > Manage Practice > Hospital Facilities > Facility NPI/Tax ID | |
| Field 32b | Other ID # | Utilities > Manage Practice > Hospital Facilities > Facility ID | |
| Field 33 | Billing Provider Info & Ph # | Utilities > Manage Practice > Staff/Provider Directory > Practice Info tab > Billing/Pay-To Information > Billing name and address fields | |
| Field 33a | Billing Provider NPI # | Utilities > Manage Practice > Staff/Provider Directory > Practice Info tab > Practice NPI field | |
| Field 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.
