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CMS-1500
wk 4
Term | Definition |
---|---|
Box 1 | Type of insurance |
Box 2 | Patient name |
Box 3 | Patient Birthday and gender |
Box 4 | Insureds name |
Box 1a | Insureds ID # |
Box 5 | Patients address |
Box 6 | Patient relationship to insured |
Box 7 | Insureds address |
Box 8 | Reserved for NUCC use |
Box 9 and a-d | Other insureds name a. Other insureds policy or grp # b. Reserved for NUCC use c. Reserved for NUCC use d. Insurance plan name or program name |
Box 10 and 10d | Is patients condition related to 10d claims codes |
Box 11 | Insureds policy grp or feca # |
Box 12 | Patient or authorized person signature |
Box 13 | Insureds or authorized persons signature |
Box 14 | Date of current illness |
Box 15 | Other date |
Box 16 | Dates patient unable to wrk in current occupation |
Box 17 | Name of referrering provider or other source |
Box 18 | Hospitalization dates related to current services |
Box 19 | Additional claim information |
Box 20 | Outside labs |
Box 21 | ICD-10 codes diagnosis or nature of illness or injury |
Box 22 | Resubmission code |
Box 23 | Prior authorization number |
Box 24a-j | 24a dates of service b. Place of service c. Emg d. Cpt/hcpcs....modifier procedure, services, or supplies e. Diagnosis pointer f. Charges g. Days or units h. East family plan I. ID qual/npi j. Rendering provider |
Box 25 | Federal tax id number |
Box 26 | Patients account # |
Box 27 | Accept assignment |
Box 28 | Total charge |
Box 29 | Amount paid |
Box 30 | Reserved for NUCC use |
Box 31 | Dr. Signature |
Box 32 | Service facility location information |
Box 33 | Billing provider info and phone # |