Home User Manual Discussion Forum Search

HCFA 1500 Claim Form

Below is an explanation of how each field on the printed HCFA 1500 Claim Form (also known as CMS 1500) is populated for medical claims. Also see Medical Insurance.  If a cell is blank, then the information is not automatically populated from the database.

Note: The requirements for e-claims are different than the requirements for paper claims. Printing a claim does not represent what is sent in an e-claim. Likewise information sent in an e-claim does not necessarily print on a paper claim.

# Field name on form Where entered
1 Medicare/Medicaid/Tricare/ChampVA/Group 
Health Plan/FECA Blk Lung/Other
2 Patient's Name

Edit Patient window, Last Name, First Name

3 Patient's Birth Date/Sex

Edit Patient window, Birthdate, Gender

4 Insured's Name Edit Patient window, Last Name, First Name for patient marked as subscriber on the Insurance Plan.
5 Patient's Address Edit Patient window, Address, City, ST, Zip, Home Phone
6 Patient's Relationship to Insured

Edit Insurance Plan window, Relationship to Patient or Edit Claim, Relationship

7 Insured's Address Edit Patient window for patient marked as subscriber on the Insurance Plan.
8 Reserved for NUCC Use  
9 Other's Insured's Name The subscriber of any secondary Insurance Plan.  Secondary coverage can be changed on Edit Claim window, Other Coverage.
9a Other Insured's Policy or Group Number Edit Insurance Plan window, Group Num (secondary plan)
10a, b, c Is Patient's Condition Related to Edit Claim window, General tab, Accident area
10d Claim Codes (designated by NUCC)  
11 Insured's Policy Group or FECA Number Edit Insurance Plan window, Group Num (primary plan)
11a Insured's Date of Birth Edit Patient window, Birthdate for patient marked as subscriber on the Insurance Plan.
11b Other Claim ID Edit Insurance Plan window
11c Insurance Plan Name or Program Name Edit Insurance Plan window, Carrier
11d Is there another Health Benefit Plan  
12 Signed, Date  
13 Authorized Signature  
14 Date of Current Illness  
15 Other Date  
16 Dates Patient Unable to Work  
17, a, b Name of Referring Provider, NPI Edit Claim window, General tab, Claim Referral
18 Hospitalization Dates  
19 Additional Claim Information  
20 Outside Lab  
21 A-L Diagnosis of Nature of Illness Procedure Info, Medical tab, ICD-9 or ICD-10 codes. The first 12 unique Diagnosis Codes in the claim will show.  ICD Ind will show 9 if using ICD-9 codes or 0 if using ICD-10 codes.
22 Resubmission Code  
23 Prior Authorization Number Edit Claim window, Predeterm Benefits field.
24A Dates of Service Edit Claim window
24B Place of Service Procedure Info, Misc tab, Place of Service
24C EMG  
24D Procedures, Services or Supplies Procedure Info, Procedure field.
24E Diagnosis Pointer Letters that correspond to the procedure's diagnoses.  Each letter is assigned to the ICD-9 code in box 21. 
24F Charges  
24G Days or Units Procedure Info, Medical tab, UnitQuantity
24I ID Qual  
24J Rendering Provider ID Edit Provider window of Treating Provider
25 Federal Tax ID Number, SSN, EIN Edit Provider window of Billing Dentist.
26 Patient Account No.  
27 Accept Assignment Edit Insurance Plan window, Assignment of Benefits.
28 Total Charge  
29 Amount Paid  
30 Rsvd for NUCC use  
31 Signature of Physician, Date  
32, a Service Facility Location Edit Provider window of billing and treating provider.
33, a Billing Provider Info & Ph Edit Provider window


Open Dental Software 1-503-363-5432