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CMS 1500 (02/12) Form At A Glance - Interactive

 This is an interactive image. Scroll over the screen to see MacPractice change. Click on an item to read documentation.
CMS 1500 (02/12) Insurance Company and Address Information
Insurance Company and Address information is typically printed above the first boxes on the top margin of the claim.
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If there is no Insurance Plan selected in Patients > Primary/Secondary > Insurance, the Insurance Address information is pulled from the Insurance Company's reference in References > Insurance Companies > Company Info.

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If there is an Insurance Plan selected in Patients > Primary/Secondary > Insurance, the Insurance Address information is pulled from the Plan Demographics in References > Insurance Companies > Plans > Demographic.

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CMS 1500 (02/12) Box 1 - Plan Type
Information is populated in this box based on Plan Type of the patient's insurance.

The Plan Type is set in the Insurance Company Reference, however it pulls from different areas depending on whether or not the patient has a plan set for their insurance.

Go to the Primary or Secondary screen and check if there is a plan assigned to the insurance carrier. If there is no plan assigned to the insurance If the Plan pop-up menu is set to "None", box 1 is controlled by the Plan Type pop-up menu in the Company Info tab of the Insurance reference. You can find this by going to the References ability, expanding the Insurance Companies node in the sidebar, then selecting the company in question, or by double-clicking the insurance in the Primary or Secondary screen. If there is a plan assigned to the insurance.

If the Plan pop-up menu is set to anything other than "None" box 1 is controlled by the Plan Type pop-up menu in the Plan reference. You can find this by going to the References ability, expanding the Insurance Companies node in the sidebar, selecting the company in question, then selecting the Plan Type pop-up menu on the Coverage tab. Make sure you have the correct plan selected.

You can also access the plan information by double-clicking the insurance in the Primary or Secondary screen.

  • The Medicare Part B plan type will check the Medicare box.
  • The Medicaid plan type will check the Medicaid box.
  • The Champus plan type will check the Tricare Champus box.
  • The Veteran Administration Plan plan type will check the ChampVA box.
  • The Preferred Provider Organization (PPO), Exclusive Provider Organization (EPO), and the Health Maintenance Organization (HMO) plan types will all check the Group Health Plan box.
  • The Other Federal Program plan type will check the FECA Black Lung box.
  • All other plan types will check the Other box.

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CMS 1500 (02/12) Box 1a - Subscriber ID Number
This information comes from the Subscriber ID field in the Insurance tab of the Patient screen.
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The patient subscriber ID will be entered automatically from the guarantor's subscriber ID on the Primary or Secondary screen.
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This information can be overridden on a per-patient basis under the Insurance tab in the Patient screen. Once you override the patient's subscriber ID the link between the patient's subscriber ID field and the guarantor's subscriber ID field will be broken; if you change any of these fields, MacPractice will not automatically update the other. To restore this broken link, delete the subscriber ID numbers from both the Subscriber ID field under the Insurance tab in the Patient screen and the Subscriber ID field of the insurance on the Primary or Secondary screen, save and then reenter the numbers on the Primary or Secondary screen.

CMS 1500 (02/12) Box 2 - Patient Name
This field pulls from the First, Middle, and Last name fields in Patient view.
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CMS 1500 (02/12) Box 3 - Patient Date of Birth
This box populates from the Birth Date field and Sex menu in Patient view. Selecting Unknown in the Sex menu will leave the patient's sex box without selection.
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CMS 1500 (02/12) Box 4 - Insured's Name
This field pulls from Relationship to Primary or Secondary menu in Patient view. If the patient's relationship to the guarantor is set to Self, then the word SAME is printed in Box 4. Otherwise, the guarantor's First, Middle, and Last name fields in Primary or Secondary view will be printed in Box 4.

If your plan type on the insurance company reference is set to Medicaid, the word “Same” is printed in Box 4 no matter what the patient’s relationship to the guarantor is. Box4-InsuredName.png

Box4-InsuredName2.png

CMS 1500 (02/12) Box 5 - Patient's Address
Information is populated from the patient's Street Address, Suite/Apt. Number, City, State, and Zip Code fields in the Patient screen. The phone number will be populated from the first listed phone number set to the Home phone type.
Box5-PatientAddress.png

CMS 1500 (02/12) Box 6 - Patient Relationship to Insured
This information comes from the patient's Relationship to Primary and Secondary pop up menu in the Patient screen. Please be aware that the Relationship to Primary is the relationship to the person on the Primary screen, not necessarily the relationship to the cardholder for the primary insurance, and so on.
Box6-PatientRelationshipToInsured.png


CMS 1500 (02/12) Box 7 - Insured's Address
This information will populate differently, depending on the patient's relationship to the guarantor.

If the patient's relationship to the guarantor is set to Self, then Box 4 will print the word "Same" and Box 7 will be blank. Otherwise, the guarantor's Street Address, Suite / Apt. Number, City, State, and Zip code fields in the Primary or Secondary screen will be printed. The phone number will be populated from the first listed phone number set to the Home phone type.

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Box7-InsuredAddress2.png

 

There are two exceptions to this rule:

  • If the plan type is set to Medicaid, then Same will be printed in Box 4 and Box 7 is left blank.
  • If the relationship is set to Self and the plan type is Medicare, Box 4 will print the word "Same" and so will Box 7.

CMS 1500 (02/12) Box 8 - RESERVED FOR NUCC USE
This box is not populated by MacPractice and should remain blank.

CMS 1500 (02/12) Box 9 - Other Insured's Name
Information is populated by the Other Insurance pop up menu in the Claim Creation window.

If the Other Insurance menu is set to None, then Box 9, 9a, and 9d will be blank.
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If the Other Insurance is set with the patient's other insurance, then Box 9 will pull the First, Middle and Last name fields for the insurance cardholder for the selected insurance.
Box9-OtherInsuredName2.png

If the Primary Insurance is Medicare, box 9 will print blank unless there is a MEDIGAP number entered in the secondary Insurance Reference.

CMS 1500 (02/12) Box 9a - Other Insured's Policy or Group Number
Information is populated by the Subscriber ID field on the associated insurance on the patient's insurance tab.
Box9a-OtherInsuredGroupNo.png

CMS 1500 (02/12) Box 9b - RESERVED FOR NUCC USE
This box is not populated by MacPractice and should remain blank.

 CMS 1500 (02/12) Box 9c - RESERVED FOR NUCC USE
This box is not populated by MacPractice and should remain blank.


CMS 1500 (02/12) Box 9d - Insurance Plan Name
This information comes from the Insurance Company name field for the Other Insurance.
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CMS 1500 (02/12) Box 10a, 10b, and 10c
This information is pulled from the Reason for Treatment tab which is found under the Incident tab of the Incident itself. If the Condition Related To menu is set to Auto Accident, the Accident State and Accident Date fields will turn red indicating that this information is required.
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CMS 1500 (02/12) Box 10d - Claim Codes (Designated by NUCC)
This box is generally blank.

If the patient has Medicare as a primary and Medicaid as a secondary, this box will be filled with MCD and their subscriber ID. To verify this information, go to the patient's Insurance tab to see the insurance information. There is not a way for MacPractice to customize this information on the claim.
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CMS 1500 (02/12) Box 11 - Insureds Policy Group Number
This box will print None if patient has Medicare as the primary insurance and the plan type is set to Medicare Part B, regardless of whether there is a secondary insurance.
Box11-InsuredGroupNo.png

Information is populated if the primary insurance plan type is not set to Medicare Part B. This information pulls from the guarantor's Group Number field. If an employer is selected in the menu, this is copied from the Group Number field in the Employer table.
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CMS 1500 (02/12) Box 11a - Insured's Date of Birth and Sex
This box populates from the Birth Date field and Sex menu for the guarantor associated to the primary insurance.
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CMS 1500 (02/12) Box 11b - Other Claim ID (Designated by NUCC)
This information is not populated by MacPractice and must be manually entered, if required.

CMS 1500 (02/12) Box 11c - Insurance Plan Name
Information is populated by the Insurance Carrier Name that is listed in the Insurance Company Reference, for the insurance under the guarantor's insurance information.
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CMS 1500 (02/12) Box 11d - Other Insurance Checkbox
If the patient has Medicare and no other insurance, the boxes will remain unchecked.

If the patient has only one insurance that is not Medicare, the No box will be selected.

If the patient has more than one insurance, the Yes box will be selected.

CMS 1500 (02/12) Box 12 - Release of Information
This box populates from the guarantor's information on the Primary or Secondary screen by selecting the Release of Information (box 12) checkbox.

"PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize release of medical or other information necessary to process the claim. I also request payment of government benefits either to myself or to the party who accepts assignment below."
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CMS 1500 (02/12) Box 13 - Signature on File
This box populates from the guarantor's information in Primary or Secondary view by selecting the Signature on File (box 13) checkbox.
This is the indicator that determines whether insurance benefits are to be received by the Provider or by the Patient. If checked, the benefits will be assigned to the provider. If unchecked, the benefits will be assigned to the patient.

It says:
"INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier of services described below."
Box13-SigOnFile.png

CMS 1500 (02/12) Box 14 - Date of Illness, Injury, or Pregnancy (LMP)
This box pulls from the Incident and will pull from a few different places, depending on the reason for treatment.

For an Illness, navigate to Incident > Claims > Symptom Dates > First Symptom Date.
(If on DDS, you'll navigate to the "CMS Claims" tab instead of Claims. If you don't see this tab, check Preferences > Ledger > Incident to enable "Display both CMS and ADA Claim View" and restart MacPractice.)
Fill out the date, and then set the "First Symptom Date Type" to "Illness". The First Symptom date will pull to box 14 and print "431" in the Qual. box.
Box14-DateOfIllness.png

For an Injury, navigate to Incident > Incident Tab, then select the "Reason for Treatment" sub-tab. The date of injury pulls from Incident > Incident tab > Reason for Treatment > Accident Date > Condition Related To. Select a Condition Related to, then mark down the Accident Date. Depending on the option marked, box 10 may be checked for the appropriate options.
Box14-DateOfIllness2.png

For a date of pregnancy navigate to Incident > Claims > Symptom Dates. When Last Menstrual Period is selected in the First Symptom menu, the First Symptom date will pull to box 14 and "484" will print in the Qual box.
Box14-DateOfIllness3.png

CMS 1500 (02/12) Box 15 - Other Date
This information pulls from Incident > Claims > Symptom Dates > Other Date. A First Symptom Date and First Symptom Date Type other than Routine Services must be present before the Other Date will pull into Box 15.
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CMS 1500 (02/12) Box 16 - Disability Dates
This information pulls from Incident > Claims > Disability > Begin Date field under the Partial and Total disability. Enter an End Date, if necessary.
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CMS 1500 (02/12) Box 17 - Name of Referring Provider
This is pulled based on the Referral listed in the charge window.
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Referrals can either be added on a per-charge basis, or you can add them to the Incident, which will cause the referral to pull to all the charges posted under that incident.
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The "Use on Claim" checkbox in the Referral Reference must be checked for it to pull to the claim.
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A two digit qualifier will pull into box 17. This qualifier is designated by the Referral Type selected in the New Charge Window.

The qualifiers are:
DN Referring Provider
DK Ordering Provider
DQ Supervising Provider
Box17-ReferringProvider4.png

CMS 1500 (02/12) Box 17a - Referring Provider Legacy Number
This information will only be only be pulled to the CMS 1500 (02/12) NPI and Legacy form. The information is pulled from the Legacy Referral Qualifier Code menu found under the Claims tab of the Insurance Company Reference.
Box17a-RefProviderLegacyNo.png

The Plan Type in the Claims tab should also be set to either a Medicaid or Medicare type.
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The Legacy number will then be pulled from the Referrals Reference under the Provider IDs tab and the related field (such as Medicare, Medicaid, and so on).
Box17a-RefProviderLegacyNo3.png

CMS 1500 (02/12) Box 17b - Referring Provider NPI Number
This field pulls from the National Provider ID (NPI) field found under the Provider IDs tab of the Referral Reference. This information will populate this field when the Referral is entered in the charge window.
Box17b-RefProviderNPINo.png

CMS 1500 (02/12) Box 18 - Hospital Admission and Discharge Dates
This box pulls from the Admitted Date and Discharge Date fields in the charge window when a facility is added.
Box18-HospitalAdmission_DischargeDate.png
Facilities can be added on a per-charge basis, they can be added to the fee in the fee schedule to pull in each time that fee is used in the charge window, or it can be added to the Incident, which will cause the facility to populate to all the charges posted under that incident.
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CMS 1500 (02/12) Box 19 - Additional Claim Information
This box pulls from Box 19 on Insurance Claim Form found under the Incident tab of the Incident.
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CMS 1500 (02/12) Box 20 - Outside Lab Checkbox
This box will default to No.

This box populates from the charge window when the Type of Service menu is set to Diagnostic Lab, a Lab is entered, and information is entered in the Lab Costs field, if necessary.
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A lab can also be added to the fee in the fee schedule to pull in each time that fee is used in the charge window.
Box20-OutsideLabs2.png

CMS 1500 (02/12) Box 21 - ICD Indicator and Diagnosis Fields
The ICD Ind. box identifies the version of the ICD code set used and is determined by the code type of the diagnosis codes themselves. ICD-9-CM codes will display a 9 within the box, while ICD-10-CM codes will display a 0.

The diagnosis codes within box 21 pull from the Diagnosis fields under the diagnosis tab in the charge window.
Box21-ICDInd_Dx.png

Diagnoses can also be pulled in when Use in Procedures is selected in the Problem List in Clinical view.
Box21-ICDInd_Dx2.png

Diagnoses can also be added to the fee in the Fee Schedule to pull in each time the fee is used in the charge window.
Box21-ICDInd_Dx3.png

Note: In the case of Treatment Plans, it is important to note that when a Treatment Plan is created and then moved to Transactions, the treatments in said treatment plan will contain the diagnosis codes that were linked when the treatment plan was created.
If your office creates treatment plans weeks or even months in advance for patients before moving them into transactions, it is important to review all charges to ensure the linked diagnosis codes are the correct ones.

CMS 1500 (02/12) Box 22 - Resubmission
The default CMS 1500 form does not pull this information in automatically. Offices may choose to write this in by hand, or update their CMS Form Reference to a custom Form that allows you to type this information in when generating a claim. This Custom CMS 1500 with resubmission fields is attached to the bottom of this article for your use.


CMS 1500 (02/12) Box 23 - Prior Authorization Number
The provider's CLIA number will print in this box if the Type of Service is set to Diagnostic Lab, and the correct number is entered in the CLIA field on the Provider IDs tab > Claim Credentials sub-tab of the User Reference.

The patient must have an Insurance Plan selected. They must also have the Plan Type set to Medicare Part B in the Patient's Insurance Company Reference > Plans Tab.
Box23-PriorAuthNo.png

Box23-PriorAuthNo2.png

For other claim types: This information is populated into the claim when an insurance requires a Prior Authorization number. It is pulled from the the Prior Authorization number entered and insurance pop-up menu selected on the Prior Auth tab of the Incident.
Box23-PriorAuthNo3.png

There must also be at least 1 remaining visit left, he prior authorization number must be selected in the insurance claim creation window from the Prior Auth pop-up menu, and a start Date must be entered for the prior authorization to pull onto the CMS form.

If there is not a Prior Auth number selected, the form will print NONE.
Box23-PriorAuthNo4.png

If the office is trying to submit a claim to Medicare, with the Type of Service set to Diagnostic Lab, and there is a Prior Auth entered on the Incident, the CLIA number will override the Prior Auth.

CMS 1500 (02/12) Box 24a - Dates of Service and Prescription Information
The shaded area for this box is populated when a prescription has been associated to a charge. There will be an N4, the NDC number for the medication, brand name of the medication, and the measurement printed in this area of the form. The prescription can be added to the charge on the Rx tab in the charge window or a medication can be associated to a fee in the Fee Schedule Reference located in the Medication table under the Speciality tab for the specific fee.
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The date(s) of service will be populated in the unshaded fields. This is pulled from the charge window Procedure Date field and the To Date field if populated.
Box24a-DOS_Prescrib2.png

CMS 1500 (02/12) Box 24b - Place of Service
This field pulls from the Place of Service menu selection in the charge window.
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CMS 1500 (02/12) Box 24c - Emergency Checkbox
This box is blank by default. MacPractice will put a Y in this field if the Emergency checkbox is checked in the charge window.
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CMS 1500 (02/12) Box 24d - Procedure and Modifier Codes
Information is populated from the Code and Modifier fields in the charge window.
Box24d-CPT_Mod.png

CMS 1500 (02/12) Box 24e - Diagnosis Pointers
This field populates based on the diagnosis codes that are entered on the diagnosis tab in the charge window. A letter (A-L) will print as a pointer to the related diagnosis code in box 21. Make sure that the primary diagnosis code is listed first in the charge window.

Box24e-DXPointer.png

If Medicare is the insurance, this box will only print a single diagnosis pointer. If there are multiple procedures on the claim that have different primary diagnosis, the pointer for the charge's primary diagnosis will pull into this field.


CMS 1500 (02/12) Box 24f - Charge Amounts
Information is populated from the Total Fee field in the charge window, which is determined by the fixed fee amount or by the number of units multiplied by the unit fee in the charge window.

These fee amounts can be found in the Unit Fee field of the fee record in the Fee Schedule.
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CMS 1500 (02/12) Box 24g - Number of Units
This field pulls from the number entered in the Units field of the charge window.
Box24g-NoOfUnits.png

CMS 1500 (02/12) Box 24h - EPSDT/Family Planning
MacPractice will put an X in this box if the Family Planning checkbox or the EPSDT checkbox is selected on the Insurance tab in Patient view.
Box24h-EPSDT_FamPlan.png

CMS 1500 (02/12) Box 24i - Rendering Provider Legacy Qualifier Code
This box will only populate when using the CMS 1500 (02/12) NPI and Legacy form AND the "Leave 24 I/J Blank" checkbox is unchecked in References > Insurance Companies > Claims Tab.
This information pulls from the Qualifier Code (box 24) that is selected in the menu under the Provider IDs tab of the Insurance Company Reference. When this is set to "Automatic", the two digit code based on the Plan Type menu selection in the Insurance Company Reference will be printed.
Box24i-LegacyQualifier.png



CMS 1500 (02/12) Box 24j - Rendering Provider Numbers
The shaded area for this box will only print when the CMS 1500 (02/12) NPI and Legacy form is used AND the "Leave 24 I/J Blank" checkbox is unchecked in References > Insurance Companies > Claims Tab. Information is pulled from the Paper ID field under the Provider IDs tab of the Insurance Company Reference.
Box24j-RenderingProviderNo.png

The unshaded area for this box is the Rendering Provider's NPI number. This information is pulled from the National Provider ID (NPI) field under the Claim Credentials tab inside the Provider tab under the User Reference.
Box24j-ProviderNo2.png

CMS 1500 (02/12) Box 25 - Tax ID
This field pulls from the information entered on the Federal or SSN field found under the Provider Numbers tab of the User Reference. The box for SSN or EIN will have an X in it based on the "Provider Tax ID on Claims" menu found under the Claim Credentials tab inside the Provider tab of the User Reference for the provider.
Box25-TaxID.png

This box also pulls from the Legacy Type Override menu under the Provider IDs tab of the Insurance Company Reference.
Box25-TaxID2.png

CMS 1500 (02/12) Box 26 - Patient Account No.
This information pulls from the Patient ID that is automatically assigned to each patient in MacPractice.
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CMS 1500 (02/12) Box 27 - Accepts Assignment
This box pulls from the Accepts Assignment column in the Provider IDs tab of the Insurance Company Reference.
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CMS 1500 (02/12) Box 28 - Total Charges
This information is pulled from the total fees included on the claim by adding the amounts for each entry in the Box 24f column.
Box28-TotalCharges.png

CMS 1500 (02/12) Box 29 - Amount Paid
By default this box will be blank.

The information for a primary claim pulls from the Patient Paid checkbox under the Sum following in Box 29 HCFA for Primary Claims on the Company Info tab of the Insurance Company Reference. This will pull in the information from the patient payment applied to the charges on the claim.
Box29-AmountPaid.png

The information for a secondary claim comes from the Patient Paid checkbox, Primary Paid checkbox, and Insurance Write-off checkbox under the Sum the following in Box 29 HCFA for Secondary Claims on the Company Info tab of the Insurance Company Reference. For the secondary claims it will take the patient paid amount, the primary insurance paid amount and the write-off amounts, total them and put them in this box.
Box29-AmountPaid2.png

CMS 1500 (02/12) Box 30 - Rsvd for NUCC Use
This box is not populated by MacPractice and should remain blank.

CMS 1500 (02/12) Box 31 - Provider Signature and Date
This box populates from the Last, First, and Suffix fields under the User Reference for the provider. The date in this box will be the claim creation date.
Box31-ProvSig_dDate.png

CMS 1500 (02/12) Box 32 - Office/Facility Information
This field can pull from several different locations:

  • If there is no lab or facility on the charge and no default facility in entered in the Office Reference, the office name found in the Office Reference will be printed.
    Box32-Office_FacilityInfo.png
  • If there is a default facility entered in the Office Reference, this will override the office address, and the default facility's address will be printed to the claim.
    Box32-Office_FacilityInfo2.png
  • If there is a facility in the charge window, the selected facility's address will be printed.
    Box32-Office_FacilityInfo3.png
  • If there is a lab entered in the charge window, and the Type of Service pop-up menu is set to Diagnostic Lab, the lab's address will print.
    Box32-Office_FacilityInfo4.png

  • If the Place of Service in the charge window is set to Home (12), the patient's name an address will print.
    Box32-Office_FacilityInfo5.png

CMS 1500 (02/12) Box 32a - Facility NPI Number
This field pulls from the NPI number for the facility, lab or office printed in the main part of box 32. See Box 32 for more information.

CMS 1500 (02/12) Box 32b - Facility Tax ID or Lab ID #
This box will only populate if using the CMS 1500 NPI and Legacy form.

This field pulls from the Facility Tax ID field in the Facility Reference that is selected as the Default Facility in the Office Reference or the facility entered in the charge window.
Box32b-FacilityTaxID.png

This information can also pull from the Lab ID # field located in the Lab Reference when the charge has a lab entered and the Type of Service pop-up menu is set to Diagnostic Lab.
Box32b-LabIDNo.png

CMS 1500 (02/12) Box 33 - Billing Provider Information
This field can pull from several different locations:

  • If the office is billing as a group, the Office name and address will print in this field as long as the following conditions are met:
    • The "Bill as Individual" checkbox in the Insurance Company Reference is not checked.
    • There must be information entered in the Practice Group ID Paper field on the Company Info tab of the Insurance Company Reference, otherwise the information entered in the Name Printed in Box 33 HCFA field in the User Reference will be printed.
  • If the "Bill as Individual" box in the Insurance Company Reference is checked, the information will pull from the Name Printed in Box 33 HCFA field of the User Reference. (This field may be named differently depending on the type of MacPractice software you are using, i.e. MacPractice DDS)
    • The address will pull from the Office address.

For more information on the Office Reference and how to get this adjusted, please refer to References - Offices.

Box33-BillingProviderInfo.png

CMS 1500 (02/12) Box 33a - Billing Provider NPI Number
This field pulls from the Group National Provider ID (NPI) field in the Office Reference if one is entered.
Box33a-BillingProviderNPINo.png

This information can also pull from the Group National Provider ID (NPI) field located in the Users Reference, which will override the Office Reference's group NPI.
Box33a-BillingProviderNPINo2.png

If the "Bill as Individual" box is checked in the Provider IDs tab of the Insurance Company Reference, this information will pull from the National Provider ID (NPI) field entered in the User Reference for the provider.
Box33a-BillingProvderNPINo3.png

CMS 1500 (02/12) Box 33b - Billing Provider Legacy Numbers
This box will only populate when using the CMS 1500 NPI and Legacy form.

This information comes from the Practice Group ID (Paper) field under the Company Info tab of the Insurance Company Reference when an office is billing as a group.
Box33b-BillingProviderLegacyNo.png

If the "Bill as Individual" box is checked in the Provider IDs tab of the Insurance Company Reference, this information will pull from the Paper ID field in the Provider IDs tab of the Insurance Company Reference.
Box33b-BillingProviderLegacyNo2.png

A two digit alpha-numeric code will pull into this box. The code is designated by the Group Qualifier Code (Box 33) in the Provider IDs inside the Insurance Company Reference.
Box33b-BillingProviderLegacyNo3.png

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