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, Medicaid ID. Note:
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| 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'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 | 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 | |
| 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 Claim Forms and copy the internal 1500-02-12 form again. |
| 24B | Place of Service | Procedure - 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 | Provider 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 |