CMS 1500 Guide
The below guide will serve as a referencing guide on where each CMS 1500 box pulls information from 3.1.
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 TRAKnet 3.1.
| CMS 1500 Box # | Description | 3.1 Pulls From | Notes | ANSI Equivalent |
|---|---|---|---|---|
| 1 | Insurance Type | Properties > Insurance > Modify Parent Insurance > Insurance Type | - | 2000B, SBR09 |
| 1a | Insured's ID # | Patient's Chart > Billing Tab > Insurance > Modify Insurance > Subscriber Number | - | 2010BA, NM109 |
| 2 | Patient's Name | Patient's Chart > Demographics | - | 2010BA, NM103-NM105 |
| 3 | Patient's Birth/Sex | Patient's Chart > Demographics | - | 2010BA, DMG02 |
| 4 | Insured's Name | PPatient'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's Chart > Demographics | - | 2010BA, N3, 01 |
| 6 | Patient Relationship to Insured | Patient's Chart > Billing Tab > Insurance > Modify > Relationship | - | 2000B, SBR, 02 |
| 7 | Insured's Address | 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 | - | - |
| 9 | Other Insured's Name | 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's Chart > Billing Tab > Secondary Insurance > Modify > Group Number | - | 2330A, NM1/IL, 09 |
| 9b | Reserved for NUCC Use | Not Changed or Populated | - | - |
| 9c | Reserved for NUCC Use | Not Changed or Populated | - | - |
| 9d | Insurance Plan Name or Program 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 > Invoice Tab > Claim Details | - | - |
| 10b | Auto Accident? State | Encounter > Invoice Tab > Claim Details | - | - |
| 10c | Other Accident? | Encounter > Invoice Tab > Claim Details | - | - |
| 10d | Reserved for Local Use | Encounter > Invoice Tab > Claim Details | - | - |
| 11 | Insured's Policy group or FECA # | - | There is no direct match for Box 11 - 11D. | |
| 11a | Insured's Date Of Birth/ Sex | 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'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 | - | - |
| 12 | Patient / Authorized Person's Signature | Billing Dashboard > Options > Claims > CMS 1500: Use Patient Signature > TRUE/FALSE | - | 2300, XLM, 10 |
| 13 | Insured's / Authorized Person's Signature | Billing Dashboard > Options > Claims > CMS 1500: Use Patient Signature > TRUE/FALSE | - | - |
| 14 | Date of Current Illness; Injury or Pregnancy (LMP) | 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 Current Illness is present | Valid qualifiers are provided in the 02/12 Instruction Manual | - |
| 15 | Other Date | Must be manually entered and printed. | - | - |
| 16 | Dates unable to work | 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's Chart > Demographics > Other > Referring Provider | Encounter > Invoice Tab > Claim Details > Referring Provider | - |
| 17a | ID / Legacy Number | 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 | Properties > Referring Provider > Modify > NPI | - | 2420E, NM1/DK, 09 |
| 18 | Hospitalization Dates | 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'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 > Invoice tab > Outside Lab Charges checkbox > $ Amount | - | 2400, PS1, 02 |
| 21 | 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 > Invoice Tab > Claim Details > Medicaid Resubmission Code | * These will appear on CMS Claims only, NOT ANSI 837 | - |
| 23 | Prior Authorization # | 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 Tab > Modify Treatment Code > Service From - To. *THIS DEAULTS TO ENCOUNTER'S DATE OF SERVICE. | This can be changed to MMDDYYYY with the setting found in Tools > Options > CMS 1500: Year Format = TRUE. Otherwise it will be in MMDDYY format. | 2400, DTP/472, 03 |
| 24b | Place of Service | Properties > Locations and Facilities > Modify the Location > Place of Service | - | 2300, CLM, 05 or 2400, SV1, 05 |
| 24c | EMG | - | *EMG means emergency. Click Hyperlink for 'Y'/“Yes” or leave blank for “No”. | - |
| 24d | CPT / HCPCS (charges) | Encounter > Invoice > Charges view | - | 2400, SV1, 01-2 |
| 24d (2) | Modifiers | Encounter > Invoice > Charges (edit mode) | Encounter > Invoice > Modify Treatment Codes > Modifiers | - |
| 24e | Diagnoses Pointer | Encounter > Invoice > Charges (edit mode) | Encounter > Invoice > Modify Treatment Codes > Dx Pointers | 2400, SV1, 07-1 |
| 24f | $ Charges | Encounter > Invoice > Charges (edit mode) | Encounter > Invoice > Modify Treatment Code(s) > Price | 2400, SV1, 02 |
| 24f Shaded | NDC | Properties > Insurance > Modify > Claim Details > CMS 1500 > Send NDC in box 24f = TRUE | - | - |
| 24g | Days / Units | - | 2400, SV1, 04 (03=UN) | |
| 24h | DPST/Family Plan | - | *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 | 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 | Legacy Number = Properties > Insurance > Legacy Numbers tab; SSN = Properties > Users; Taxonomy Code = Properties > Users; UPIN = Properties > Users. | - |
| 25 | Fed. Tax ID # | 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's Chart > Demographics | - | 2300, CLM, 01 |
| 27 | Accept Assignment | 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 | *Totals the charges of the CPT Codes. Up to 6 CPT on CMS Claim | 2300, CLM, 02 | |
| 29 | Amount 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 | - | - |
| 31 | Sig. Of Provider /Physician / Date Signed | REQUIRED: Properties > Users > Modify Provider > Provider Info > SOF = True. Display as <Physician's Name>: Tools > Options > Claims > CMS 1500: Use Provider Signature = TRUE. Display as 'Signature on File': Tools > Options > Claims > CMS 1500: Use Provider Signature = FALSE | *Date Signed pulls from system clock of computer. | 2300, CLM, 06 |
| 32 | Service Facility Location Info | 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 | Properties > Locations and Facilities > Modify the Location > NPI | - | 2310C, NM1/77, 09 |
| 32b | Legacy Number | IF Parent Insurance > Send Legacy Numbers = TRUE, THEN Legacy Number = Parent Insurance > Facilities Tab | - | - |
| 33 | Billing Provider Info & PH # | 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 | 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 | *Legacy Number = Parent Insurance > Practice Legacy Number; *Taxonomy Code = Home Tab > System > Users & Providers > Practice Info > Practice Taxonomy Code. | - |
page revision: 16, last edited: 16 Jul 2021 20:16
