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CMS-1500 Details

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.