Cms 1500
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Block1. | Medicare box
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| Block1a | Insurance ID number
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| Block2. | Patient name (last name, first name, Middle initial)
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| Block3. | patient birth date/sex
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| Block4. | Insurance name (last name, first name, middle initial)
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| Block5 | Patient address , city, state , zip code, Telephone
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| Block6. | Patient relationship to insured
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| Block7. | Insurance address , city, state, zip code, telephone
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| Block8. | Reserved for Nucc use
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| Block9. | other insured name (last name, first name, middle initial)
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| block9a. | Other insured policy or group number
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| block9b. | Reserved for NUCC use
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| block9c. | Reserved for NUCC use
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| block9d. | Insurance plan name or program name
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| Block10 | is the patient condition related to
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| Block10a | employment
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| Block10b | auto accident
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| Block10c | other accident
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| Block10d |
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| Block11 | insurance policy group of feca number
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| Block11a | insurance date of birth / sex
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| Block11b | other claim
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| Block11c | insurance plan name or program name
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| Block11d | another health benefits plan
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| Block12 | patient or authorized person signature
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| Block13 | insurance or authorized person signature
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| Block14 | dates of current illness, injury pregnancy
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| Block15 | other date
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| Block16 | dates patent unable to work
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| Block17 | leave blank
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| Block18 | hospital date related to current service
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| Block19 | leave blank
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| Block20 |
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| Block21 | diagnosis or nature of illness or injury
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| Block22 | Resubmission number
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| Block23 | Prior authorization number
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| Block24a | dates of service
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| Block24b | place of service
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| Block24c | Emg
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| Block24d | Procedures service or supplies
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| Block24e | Diagnosis pointer
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| Block24f | $ charges
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| Block24G | Days or units
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| Block24H | EPSDT
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| Block24I | ID qual
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| Block24J | Rendering provider ID
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| Block25 | Federal Tax I.d number
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| Block26 | patients account NO.
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| Block27 | accept assignment
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| Block28 | total charge
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| Block29 | amount paid
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| Block30 | Rsvd for Nucc use
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| Block31 | Signature of physician or supplier includes degrees credential
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| Block32 | service facility location information
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| Block33 | Billing provider information & ph #
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
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To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
Jackie_20
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