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.
  • 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 Insurance Plan 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 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.
24I ID Qual Fixed text ZZ.
24J Rendering Provider ID NPI Number of treating Provider and Provider Speciality determines taxonomy code unless a Taxonomy Code Override is entered.
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.