Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
CMS 1500
Block numbers and descriptions
| Term | Definition |
|---|---|
| Box 1 | Type of Health Insurance Coverage Applicable to the Claim |
| Box 2 | Patient's Name |
| Box 3 | Patient's Birth Date |
| Box 4 | Insured's Name |
| Box 5 | Patient's Address and Telephone Number |
| Box 9 | Other Insured's Name |
| Box 9a | Other insured's policy or group number |
| Box 10a-c | Patient's condition related to: |
| Box 11 | Insured's policy group or FECA number |
| Box 11a | Insured's Date of Birth |
| Box 11b | Employer's Name or School Name |
| Box 14 | Date of Current Illness |
| Box 17 | Name of Referring Provider or Other Source |
| Box 17b | Referring Physician's NPI |
| Box 19 | Reserved for Local Use |
| Box 21 | Diagnosis or Nature of Illness or Injury |
| Box 24a | Date of Service |
| Box 24b | Place of Service |
| Box 24d | Procedures, Services, or Supplies code |
| Box 24e | Diagnosis Pointer |
| Box 24f | Charges |
| Box 24g | Days or Units |
| Box 24j | Rendering Provider NPI |
| Box 25 | Federal Tax ID Number |
| Box 26 | Patient's Account Number (if desired) |
| Box 27 | Accept Assignment |
| Box 28 | Total charge |
| Box 29 | Dollar Amount |
| Box 31 | Signature of Physician or Supplier |
| Box 32 | Service Facility Location Information |
| Box 32a | Service Facility NPI |
| Box 33 | Billing Provider |
| Box 33a | Billing Provider NPI |
| Block 1-13 | Patient Demographics |
| Blocks 14-33 | Patient's Condition and the Provider's Information |
| Box 1a | Insured's ID Number |
| Box 6 | Patient's Relationship to Insured |
| Box 7 | Insurance Primary to Medicare, Insured's Address and Telephone number |
| Box 8 | Reserved for NUCC use |
| Box 9b | Reserved for NUCC use |
| Box 9c | Reserved for NUCC use |
| Box 9d | Insurance Plan/Program Name |
| Box 11c | Insurance Plan/Program Name |
| Box 11d | Leave Blank |
| Box 12 | Patient's or Authorized Person's Signature |
| Box 13 | Medigap Benefits, Insured/Authorized Person's Signature |
| Box 15 | Leave Blank |
| Box 16 | Dates Patient Unable to Work in Current Occupation |
| Box 17a | Leave Blank |
| Box 18 | Service Furnished as a Result of, or Subsequent to, a Related Hospitalization |
| Box 20 | Diagnostic and Purchased Test |
| Box 21 | Patient's Diagnosis/Condition |
| Box 22 | Leave Blank |
| Box 23 | Prior Authorization Number |
| Line 24 | Service Line |
| Box 24c | Leave Blank |
| Box 24h | Leave Blank |
| Box 24i | ID Qualifier |
| Box 30 | Leave Blank |
| Box 32b | ID Qualifier or PIN |
Created by:
rose731red
Popular Medical sets