CMS 1500 Guide

The below guide will serve as a referencing guide on where each CMS 1500 box pulls information from TRAKnet 2.0 and 3.0.

CMS 1500 Guide

Below is a guide which will walk you through each box of the CMS 1500 02-12 form and how to update each in both TRAKnet 2.0 and TRAKnet 3.0.

CMS 1500 Box # Description 2.0 Pulls From 3.0 Pulls From Notes ANSI Equivalent
1 Insurance Type Parent Insurance > Type Code Properties > Insurance > Modify Parent Insurance > Insurance Type - 2000B, SBR09
1a Insured's ID # Patient Insurance > Subscriber Number Patient's Chart > Billing Tab > Insurance > Modify Insurance > Subscriber Number - 2010BA, NM109
2 Patient's Name Patient File > Demographics Tab Patient's Chart > Demographics - 2010BA, NM103-NM105
3 Patient's Birth/Sex Patient File > Demographics Tab Patient's Chart > Demographics - 2010BA, DMG02
4 Insured's Name Patient Insurance > Last Name, First Name, MI Patient's Chart > Billing Tab > Insurance > Modify Insurance > First Name, Last Name, Middle of Insured If Relationship = Self, will be Patient's Chart > Demographics 2330A, NM1/IL, 03 + 2330A, NM1/IL, 04
5 Patient's Address Patient File > Demographics Tab Patient's Chart > Demographics - 2010BA, N3, 01
6 Patient Relationship to Insured Patient Insurance > Relationship Patient's Chart > Billing Tab > Insurance > Modify > Relationship - 2000B, SBR, 02
7 Insured's Address Patient Insurance > Address, City, State, Zip, Phone Patient's Chart > Billing Tab > Insurance > Modify > Address If Relationship = Self, will be Patient's Chart > Demographics -
8 Reserved for NUCC Use Not Changed or Populated Not Changed or Populated - -
9 Other Insured's Name Patient Insurance(2nd) > Last Name, First Name, MI Patient's Chart > Billing Tab > Secondary Insurance > Modify > First Name, Last Name, Middle of Insured If Relationship = Self, will be Patient's Chart > Demographics 2330A, NM1/IL, 03 - 05
9a Other Insured's Group Name or Policy Number Patient Insurance(2nd) > Group Number Patient's Chart > Billing Tab > Secondary Insurance > Modify > Group Number - 2330A, NM1/IL, 09
9b Reserved for NUCC Use Not Changed or Populated Not Changed or Populated - -
9c Reserved for NUCC Use Not Changed or Populated Not Changed or Populated - -
9d Insurance Plan Name or Program Name Patient Insurance(2nd) > Group Name Patient's Chart > Billing Tab > Secondary Insurance > Modify > Group Name - 2330B, NM1/PR, 09
10 Is Patient's Condition Related To: - - - 2300, CLM, 11
10a Employment? Encounter > Claim Details > Employment Related Encounter > Invoice Tab > Claim Details - -
10b Auto Accident? State Encounter > Claim Details > Auto Accident, State Encounter > Invoice Tab > Claim Details - -
10c Other Accident? Encounter > Claim Details > Other Accident Encounter > Invoice Tab > Claim Details - -
10d Reserved for Local Use Encounter > View > Claims > CMS1500 Preview > 10d Encounter > Invoice Tab > Claim Details - -
11 Insured's Policy group or FECA # Patient Insurance > Group Number Patient's Chart > Billing Tab > Insurance > Modify > Group Number - There is no direct match for Box 11 - 11D.
11a Insured's Date Of Birth/ Sex Patient Insurance > Birthdate, Gender Patient's Chart > Demographics > Birthdate, Gender If Relationship is NOT self, then will be located in Insurance > Insured -
11b Other Claim ID (Designated by NUCC) - - - -
11c Insurance Plan/Program Name Patient Insurance > Group Name Patient's Chart > Billing Tab > Insurance > Modify > Group Name - -
11d Is There another health / benefit plan? IF PATIENT HAS ONE INSURANCE, THEN 11D = NO, OTHERWISE 11D = YES IF PATIENT HAS ONE INSURANCE, THEN 11D = NO, OTHERWISE 11D = YES - -
12 Patient / Authorized Person's Signature Options > CMS1500 > Use Patient Signature; TRUE/FALSE Billing Dashboard > Options > Claims > CMS 1500: Use Patient Signature > TRUE/FALSE - 2300, XLM, 10
13 Insured's / Authorized Person's Signature Options > CMS1500 > Use Patient Signature; TRUE/FALSE Billing Dashboard > Options > Claims > CMS 1500: Use Patient Signature > TRUE/FALSE - -
14 Date of Current Illness; Injury or Pregnancy (LMP) Encounter's Date of Service Encounter > Date of Service Encounter > Invoice Tab > Claim Details > Date of Current / Injury 2300, DTP/439, 03
14 Qual. Contains a qualifier to accommodate 3-byte qualifier Autopopulates if Date of Illness present Autopopulates if Date of Current Illness is present Valid qualifiers are provided in the 02/12 Instruction Manual -
15 Other Date Must be manually entered and printed. Must be manually entered and printed. - -
16 Dates unable to work Claim Details > Unable to Work: From - To Encounter > Invoice Tab > Claim Details > Unable to Work From - To dates - 2300, DTP/360/361/or 314, 03
17 Name of Referring Prov. / Other Patient File > Referring Tab Patient's Chart > Demographics > Other > Referring Provider Encounter > Invoice Tab > Claim Details > Referring Provider -
17a ID / Legacy Number IF Parent Insurance > Send Legacy Numbers = TRUE, THEN Box 17a Identifier can be either: Legacy Number, SSN, Taxonomy Code or UPIN. *USE Box 17a qualifier = T/F IF Properties > Insurance > Parent Insurance > Send Legacy Numbers = TRUE, THEN Box 17a Identifier can be either: Legacy Number, SSN, Taxonomy Code or UPIN. *USE Box 17a qualifier = T/F Legacy Number = Parent Insurance > Legacy Numbers tab; SSN = Properties > Referring Providers; Taxonomy Code = Properties > Referring Providers; UPIN = Properties > Referring Providers -
17b NPI/NPI number Home Tab > System > Referring Providers > NPI Properties > Referring Provider > Modify > NPI - 2420E, NM1/DK, 09
18 Hospitalization Dates Encounter > Claim Details > Hospitalization: From - To Encounter > Invoice tab > Claim Details > Hospitalization From - To dates - -
19 Additional Claim Information (Designated by the NUCC) TO POPULATE WITH REFERRING DOCTOR DATE LAST SEEN AND NPI: Patient Insurance > Send NPI and Date Last Seen = TRUE, Patient Insurance > NPI to Send with Date Last Seen = Referring NPI or Supervising NPI. TO MANUALLY POPULATE FIELD: Encounter > View > Claims > CMS 1500 Preview and select blue hyperlink to free type text. TO POPULATE WITH REFERRING DOCTOR, DATE LAST SEEN AND NPI: Patient's Insurance from Properties > Insurance > Claim Details tab > ANSI 837 and CMS 1500 Send NPI and Date Last Seen = TRUE; NPI to Send with Date Last Seen = Referring Provider or Supervising Provider. TO MANUALLY POPULATE FIELD: Encounter > Invoice Tab > Claim Details > Type into CMS 1500 Box 19. - -
20 Outside Lab/ Charges Encounter > Claim Details > 'Outside Lab Charges' checkbox; $ Amount Encounter > Invoice tab > Outside Lab Charges checkbox > $ Amount - 2400, PS1, 02
21 Diagnoses Codes Encounter > Invoice > Diagnoses Codes Encounter > Diagnosis tab > Visit Problems; Populated on Invoice > Invoice > Charges (edit mode) To Auto-Populate Diagnoses codes: Billing Dashboard > Options > Billing > Auto-fill Diagnoses Pointers 2300, HI, 01-2
22 Resubmission Encounter > Claim Details > Medicaid Resubmission Code, Original Reference Number Encounter > Invoice Tab > Claim Details > Medicaid Resubmission Code * These will appear on CMS Claims only, NOT ANSI 837 -
23 Prior Authorization # Patient File > Referring Tab > Authorization Number Patient's Chart > Billing Tab > Authorization > Add Encounter > Invoice Tab > Claim Details > Prior Authorization Number 2300 or 2400, REF/G1, 02
24a Date(s) of Service Encounter > Invoice > Modify Treatment Code > Service From - To. *THIS DEFAULTS TO ENCOUNTER'S DATE OF SERVICE Encounter > Invoice Tab > Modify Treatment Code > Service From - To. *THIS DEAULTS TO ENCOUNTER'S DATE OF SERVICE. - 2400, DTP/472, 03
24b Place of Service Home Tab > System > Location and Facilities > Place of Service Properties > Locations and Facilities > Modify the Location > Place of Service - 2300, CLM, 05 or 2400, SV1, 05
24c EMG Encounter > View > Claims > CMS1500 Preview > 24c - *EMG means emergency. Click Hyperlink for 'Y'/“Yes” or leave blank for “No”. -
24d CPT / HCPCS (charges) Encounter > Invoice > Treatment Codes Encounter > Invoice > Charges view - 2400, SV1, 01-2
24d (2) Modifiers Encounter > Services View of Invoice > M1 - M4 Encounter > Invoice > Charges (edit mode) Encounter > Invoice > Modify Treatment Codes > Modifiers -
24e Diagnoses Pointer Encounter > Services View of Invoice > Dx1-Dx4 Encounter > Invoice > Charges (edit mode) Encounter > Invoice > Modify Treatment Codes > Dx Pointers 2400, SV1, 07-1
24f $ Charges Encounter > Services View of Invoice > Fee Encounter > Invoice > Charges (edit mode) Encounter > Invoice > Modify Treatment Code(s) > Price 2400, SV1, 02
24f Shaded NDC System > Insurances > Modify > CMS1500 > Send NDC in box 24f = TRUE Properties > Insurance > Modify > Claim Details > CMS 1500 > Send NDC in box 24f = TRUE - -
24g Days / Units Encounter > Services View of Invoice > Units Encounter > Invoice > Modify Treatment Code(s) > Quantity - 2400, SV1, 04 (03=UN)
24h DPST/Family Plan Encounter > View > Claims > CMS1500 Preview > 24h. IF related to EPSDT select hyperlink for 'Y' or “Yes”, otherwise leave blank. - *The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program is the child health component of Medicaid. It's required in every state and is designed to improve the health of low-income children, by financing appropriate and necessary pediatric services. -
24i ID / QUAL. Claims tab on modify insurance Claims tab on modify insurance 24i - check / uncheck 2 char qualifier 2310B or 2420A, NM1/82, 09 (08=XX)
24j (shaded) Rendering Prov. ID # (1B, G2, etc.) IF Parent Insurance > Send Legacy Numbers = TRUE, THEN Box 24j Identifier can be either: Legacy Number, SSN, Taxonomy Code or UPIN *USE Box 24j qualifier = T/F IF Parent Insurance > Send Legacy Numbers = TRUE, THEN Box 24j Identifier can be either: Legacy Number, SSN, Taxonomy Code or UPIN *USE Box 24j qualifier = T/F Legacy Number = Properties > Insurance > Legacy Numbers tab; SSN = Properties > Users; Taxonomy Code = Properties > Users; UPIN = Properties > Users. -
25 Fed. Tax ID # FEIN (TAX ID): Home Tab > System > Users & Providers > Practice FEIN. SSN: Home Tab > System > Users & Providers > Practice FEIN needs to be blank and Home Tab > System > Users & Providers > SSN needs to be filled out. FEIN (Tax ID): Properties > Users > Modify Provider > Practice Info > Practice FEIN SSN: Properties > Users > Modify Provider > SSN needs to be filled out and FEIN needs to be blank. * If SSN is not filled out, then Box 25 will be a blank SSN. 2010AA , REF, 02 (REF01=EI or SY)
26 Pat. AccntNO Patient File > Demographics Tab Patient's Chart > Demographics - 2300, CLM, 01
27 Accept Assignment Encounter > View > Claims > CMS1500 Preview > 27. Select box for YES or NO. YES is always checked by default. Properties > Insurance > Modify > Details Tab > Claim Information > Has Assignment > TRUE/FALSE "*OPTIONAL. Complete this box to indicate that the provider accepts assignment of Medicare/Medicaid benefits. Submitting a claim to Medicare/Medicaid automatically indicates the provider accepts assignment." 2300, CLM, 07
28 Total Charge Box 24F 1+…+ 24F 6 Box 24F 1+…+ 24F 6 *Totals the charges of the CPT Codes. Up to 6 CPT on CMS Claim 2300, CLM, 02
29 Amount Paid Encounter > Invoice > Total Paid Encounter > Invoice > Total Paid IF Insurance > Claim Details > CMS 1500 > Box 29 Amount (Primary)= (selected payment type(s)) THEN the combined payment amount for the type(s) will appear in Box 29 for primary insurance CMS 1500 forms. IF Insurance > Claim Details > CMS 1500 > Box 29 Amount (Other)= (selected payment type(s)) THEN the combined payment amount for the type(s) will appear in Box 29 for other than primary insurances CMS 1500 forms. 2300, AMT/F5, 02
30 Reserved for NUCC Use Not Changed or Populated Not Changed or Populated - -
31 Sig. Of Provider /Physician / Date Signed REQUIRED: Home Tab > System > Users & Providers > SOF = TRUE. Display as <Physicians Name>: Options > CMS 1500 > Use Providers Signature = TRUE. Display as 'Signature of File': Options > CMS 1500 > Use Providers Signature = FALSE. REQUIRED: Properties > Users > Modify Provider > Provider Info > SOF = True. Display as <Physician's Name>: Billing Dashboard > Options > CMS 1500 > CMS 1500: Use Provider Signature = TRUE. Display as 'Signature on File': Billing Dashboard > Options > CMS 1500 > CMS 1500: Use Provider Signature = FALSE *Date Signed pulls from system clock of computer. 2300, CLM, 06
32 Service Facility Location Info Encounter - "Top Right Corner" > Location from Drop-Down Encounter > Visit Note > Facility drop down menu *Location can be modified from Properties > Locations/Facilities. *When POS = 12(DME), Parent Insurance > CMS 1500 > Use Box 32 = FALSE. Box 32 will be blank. 2310C, NM1/77, 03
32a NPI Home Tab > System > Location and Facilities > NPI Properties > Locations and Facilities > Modify the Location > NPI - 2310C, NM1/77, 09
32b Legacy Number IF Parent Insurance > Send Legacy Numbers = TRUE, THEN Then Legacy Number = Parent Insurance > Facilities Tab; IF Parent Insurance > Send Legacy Numbers = TRUE, THEN Legacy Number = Parent Insurance > Facilities Tab - -
33 Billing Provider Info & PH # Home Tab > System > Users & Providers > Practice Info Section. When 'Use Practice Defaults' = TRUE: Then Practice Name, FEIN, NPI, Address and Phone are defaulted from Options > My Practice. When 'Use Practice Defaults' = FALSE: Then Practice Name, FEIN, NPI, Address and Phone can be overridden. Properties > Users > Modify Provider > Practice Info Section. When 'Use Practice Defaults' = TRUE: Then Practice Name, FEIN, NPI, Address and Phone are defaulted from Billing Dashboard > Options > My Practice. When 'Use Practice Defaults' = FALSE: Then Practice Name, FEIN, NPI, Address and Phone can be overridden. - 2010AA, NM1/85, 03
33a Billing NPI Home Tab > System > Users & Providers > Practice Info Section. When 'Use Practice Defaults' = TRUE: Then NPI is defaulted from Options > My Practice. When 'Use Practice Defaults' = FALSE: Then NPI can be overridden. Practice NPI can also be overridden at the Parent Insurance: IF Parent Insurance > Use Practice NPI = TRUE, THEN 'Practice NPI' from Home Tab > System > Users & Providers > Practice Info Section is used. IF Parent Insurance > Use Practice NPI = FALSE, THEN Parent Insurance > Billing NPI is used. Properties > Users > Modify Provider > Practice Info Section. When 'Use Practice Defaults' = TRUE: Then NPI is defaulted from Billing Dashboard > Options > My Practice. When 'Use Practice Defaults' = FALSE: Then NPI can be overridden. Practice NPI can also be overridden at the Parent Insurance: IF Parent Insurance > Use Practice NPI = TRUE, THEN 'Practice NPI' from Home Tab > System > Users & Providers > Practice Info Section is used. IF Parent Insurance > Use Practice NPI = FALSE, THEN Parent Insurance > Billing NPI is used. To send the Facility NPI as the Billing NPI, go to Properties > Insurance > ANSI 837 and CMS 1500 > Send Facility NPI as Billing NPI = TRUE. 2010AA/NM1/85/09 (08 = XX)
33b Billing Legacy Number/Taxonomy Code IF Parent Insurance > Send Legacy Numbers = TRUE, THEN Box 33b Identifier can be either: Legacy Number or Taxonomy Code *USE Box 33b qualifier = T/F IF Parent Insurance > Send Legacy Numbers = TRUE, THEN Box 33b Identifier can be either: Legacy Number or Taxonomy Code *USE Box 33b qualifier = T/F *Legacy Number = Parent Insurance > Practice Legacy Number; *Taxonomy Code = Home Tab > System > Users & Providers > Practice Info > Practice Taxonomy Code. -
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