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 Edit Patient Information Window, Medicaid ID.

Note:
  • If Medicaid ID is entered for patient, Medicaid # is checked on form.
  • If no Medicaid ID is entered, and Insurance Filing Code does not equal Medicaid, Champus, or Veterans, then Group Health Plan will be checked on form.

2 Patient's Name Edit Patient Information window, Last Name, First Name
3 Patient's Birth Date/Sex Edit Patient Information window, Birthdate, Gender
4 Insurer's Name Edit Patient Information, Last Name, First Name for patient marked as subscriber on the insurance plan.
5 Patient's Address Edit Patient Information window, Address, City, ST, Zip, Home Phone
6 Patient's Relationship to Insured

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

7 Insurer's Address Edit Patient Information window for patient marked as subscriber on the insurance plan.
8 Reserved for NUCC Use
9 Other's Insurer's Name The subscriber of any secondary insurance plan. Secondary coverage can be changed on Edit Claim window, Other Coverage.
9a Other Insurer's Policy or Group Number Edit Insurance Plan window, Group Num (secondary plan)
10a, b, c Is Patient's Condition Related to Edit Claim - General Tab, Accident area
10d Claim Codes (designated by NUCC)
11 Insurer's Policy Group or FECA Number Edit Insurance Plan window, Group Num (primary plan)
11a Insurer's Date of Birth Edit Patient Information 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 Procedures - Medical Tab, ICD codes. The first 12 unique diagnoses 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, Tooth Range Edit Claim window, Procedure Info window. Tooth Range (SystemandTeeth) only will show above the date of service in the claim form released in version 18.1. To update the claim form, go to Printed Claim Form Setup and copy the internal 1500-02-12 form again.
24B Place of Service Procedures - Misc Tab, Place of Service
24C EMG
24D Procedures, Services or Supplies Procedure Info window, Procedure field.
24E Diagnosis Pointer Letters that correspond to the procedure's diagnoses. Each letter is assigned to the ICD code in box 21.
24F Charges
24G Days or Units Procedures - Medical tab, UnitQuantity
24H
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