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. Claim Form 1500_02_2012 has the most updated fields for HCFA 1500 available in Open Dental, and should be used by most practices.
Some fields require Medical Insurance features to be enabled. If a cell is blank, information is not automatically populated from the database.
Note: Requirements for e-claims are different than 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, Medicaid ID. Note:
|
| 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 | Insurance Plan window, Relationship to Patient or Claim, 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 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, Injury, or Pregnancy | Edit Claim - Medical Tab. Field must be added to form manually. |
| 15 | Other Date | Edit Claim window, Medical tab. Field must be added to form manually. |
| 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 | Edit Claim window, Medical tab. Field must be added to form manually. |
| 21 A-L | Diagnosis of Nature of Illness | Procedure - 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, Original Reference Num | Edit Claim - Misc Tab, Correction Type, Original Reference Num |
| 23 | Prior Authorization Number | Edit Claim window, Misc tab, Prior Authorization (rare) |
| 24 (supplemental) | Supplemental information is filled from various fields. Drug NDC from Procedure Info, Medical tab. Narrative from E-Claim Note box in Procedure Info. System and Teeth, treatment area of procedure. Limited to 61 characters. | |
| 24A | Dates of Service | Edit Claim window, Procedure Info window. |
| 24B | Place of Service | Procedure - Misc Tab, Place of Service |
| 24C | EMG | Procedures - Medical tab, Is Emergency. P#IsEmergency must be added to each procedure line on the claim form to show. |
| 24D | Procedures, Services or Supplies | Procedure Info window, Procedure field. For modifiers, enter these in the Procedure Info Window, Medical tab, Mods. |
| 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 | NPI Number 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 | Service Facility Location Information | Physical treating address of Practice or Clinic associated with claim |
| 32, a | NPI Number of Billing Provider | |
| 33 | Billing Provider Info & Ph | Billing or Pay To address of Practice or Clinic associated with claim. If no Billing or Pay To address, Physical Treating address is used. |
| 33, a | NPI Number of Billing Provider |