CMS 1500 Form and Corresponding Fields

This article details the CMS 1500 Health Insurance Claim Form, each corresponding "Box" and fields in the Valant EHR.  

• Box 1: Shows the type of health insurance coverage applicable to this claim by the appropriately checked box. Insured ID Number is from the Insurance ID Number field in the Insurance 1 tab on View/Edit Charges and the patient demographics.  
  • The insurance type is indicated within Valant for each Insurance Company on Persons & Institutions | Insurance Companies | Insurance tab | Type
  • The insurance information on the claim form will be the assigned insurance information on View/Edit Charges for the date of service.

• Box 2: Patient’s last name, first name, and middle initial (if any). This is a required field.
  • This information is located within Valant within Persons & Institutions | Patients | Demographics tab
• Box 3 Description:
  • Enter the patient's 8-digit birth date (MM | DD | CCYY) and sex. This information is pulled from Valant in Persons & Institutions | Patients | Demographics.
• Box 4: If there is insurance is Medicare leave blank. If the insurance primary to medicare , either through the patient's or spouse's employment or any other source, list the name of the insured here. This information is located within Valant within Persons & Institutions | Patients | Insurance tab
• Box 5 Description: Patient's mailing address and telephone number. 

►This information is located within Valant within Persons & Institutions | Patients | Demographics

Box 6

Box 6 Description: Patient's relationship to insured when Box 4 is completed.

► This information is located within Valant within Persons & Institutions | Patients | Insurance tab | Relation to subscriber:

Box 7

Box 7 Description: The insured's address and telephone number. Complete Box only when Boxes 4, 6, and 11 are completed.

► If the patient is insured through a parent or spouse, the insured’s address and telephone number is entered within Valant within Persons and Institutions | Guarantors. 

► After the guarantor has been added, the guarantor will be listed as an option to select from the guarantor drop-down menu within Persons and Institutions | Patients | Insurance tab | Subscriber.

 Box 8

 Box 8 Description: CMS Form version 02/12: Leave blank.

► This information does not need to be entered within Valant.

Box 9

 Box 9 Description: The last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in Box 2. If no Medigap benefits are assigned, leave blank. 

► This information does not need to be entered within Valant.

Box 10 

Box 10 Description: Boxes 10a through 10c - Check "YES" or "NO" to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in Box 24. Enter the State postal code. Any Box checked "YES" indicates there may be other insurance primary to Medicare. Identify primary insurance information in Box 11.

Box 10d - Use this Box exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by MCD.

► If Box 10 is applicable, this information can be entered within Valant by navigating to Persons and Institutions | Patients and selecting the Other Details tab.

Box 11

Box 11 Description: If there is insurance primary to Medicare, the insured's policy or group number is entered here. Box 11a - The insured's 8-digit birth date (MM | DD | CCYY) and sex if different from Box 3. Box 11b – List the employer's name, if applicable. Box 11c - Enter the 9-digit PAYERID number of the primary insurer. Box 11d – Not required by Medicare. 

► If Box 11a is applicable, this information can be entered within Valant by navigating to Persons and Institutions | Patients and selecting the Other Details tab. 

► Box 11b is not required information 

► Box 11c is indicated within Valant within Persons and Institutions | Insurance Companies | EDI Payor ID

Box 12

Box 12 Description: This indicates that the patient has signed paperwork authorizing the clinic to release their PHI to the insurance company. 

►The information for box 12 is indicated within Persons & Institutions | Patients | Demographics | Info release authorized 

Box 13

Box 13 Description: A signature, or signature on file, for Box 13 indicates that the insurance company is authorized to pay the clinic directly. 

► The information for box 13 is indicated within Persons & Institutions | Patients | Demographics | Signature on file. Check the box if the signature on file box if the insurance company is authorized to pay the clinic directly.

Box 14

CMS Description Box 14: The 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of current illness, injury, or pregnancy.

► The information for Box 14 is entered within Valant by navigating to Persons and Institutions | Patients and selecting the Other Details tab | Date of Current Illness, Injury or Pregnancy (Box 14).

 Box 15

► The information for Box 15 is entered within Valant by navigating to Persons and Institutions | Patients and selecting the Other Details tab | Other Date (Box 15).

Box 16

Box 16 Description: If the patient is employed and is unable to work in his/her current occupation, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when patient is unable to work. 

► The information for Box 16 is entered within Valant by navigating to Persons and Institutions | Patients and selecting the Other Details tab | Unable to Work Dates (Box 16).

Box 17

Box 17 Description: The name of the referring or ordering physician if the service or Box was ordered or referred by a physician. 

► The information for Box 17 is entered within Valant by navigating to Persons and Institutions | Patients and selecting the Other Details tab | Referring Provider (Box 16).

Box 18

Box 18 Description: Enter either an 8-digit (MM | DD | CCYY) or a 6-digit (MM | DD | YY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

► The information for Box 18 is entered within Valant by navigating to Persons and Institutions | Patients and selecting the Other Details tab | Hospitalization Dates (Box 18).

Box 19

Box 19 Description: Box 19 is used to identify additional information about the patient's condition or the claim. 

► The information for Box 19 is indicated within Valant by navigating to Billing | View/Edit Charges | Insurance tab | CMS-1500 Box 19. 

Box 20 

Box 20 Description: This box is completed when billing for diagnostic tests subject to the anti-markup payment limitation.

► Box 20 is not indicated within Valant. 

Box 21

Box 21 Description: The patient's diagnosis/condition.

► Diagnoses are added within the patient chart by navigating to Open Patient Chart | Diagnoses | New Diagnoses. For more information about adding a diagnoses, review the Adding a Diagnoses article.  

Box 22

Box 22 Description: Box 22 is used to list the Original Reference Number for resubmitted/corrected claims. When resubmitting a claim, enter the appropriate frequency code:

•    6 - Corrected Claim

•    7 - Replacement of Prior Claim 

•    8 - Void/Cancel Prior Claim 

The Original Reference Number is assigned by the destination payer or receiver to indicate a previously submitted claim or encounter. This is also known as the Claim Reference Number or ICN.

This box is not intended for use with original claim submissions. 

►There is not a location within Valant to enter a resubmission code for box 22. However, most clearinghouses provide the option to edit box 22. Please check with your clearinghouse for more information. 

Note: if you do not utilize a clearinghouse and mail printed claims, you can manually enter this information on a printed claim instead. 

Box 23

Box 23 Description: The prior authorization number for those procedures requiring QIO prior approval.

► Prior authorization information is indicated within Valant within Person & Institutions | Patients | Authorizations | New Authorization

Box 24

Box 24 Description: The information added within Box 24 refers to the billed service.  

► The information for 24A – 24H is indicated within the billing module when a charge is created for a date of service. For more information on creating charges for a date of service, please reference the Record Appointments or Create Manual Charge. 

Although it is rather rare, some payors require that a taxonomy code be included for the Rendering Provider ID field (24J) on a CMS 1500 Claim form. The taxonomy code will refer to the provider’s specialty. For more information on how to add a provider taxonomy code in Box 24J for a CMS 1500 form, please review the Taxonomy article.

For electronic claims, the taxonomy code is controlled by the "Specialty" dropdown box. The Specialty dropdown box can be accessed by clicking on Persons and Institutions | Providers or by clicking on Persons and Institutions | Practice. For more information on how to add a provider taxonomy code for an electronic claim, please review the List of Taxonomy Codes article. 

Box 25

Box 25 Description: The provider of service Federal Tax ID (Employer Identification Number or Social Security Number).

► If practice billing type is set to “Non-Person”, billing info from Persons and Institutions | Practice will be used to populate Box 25, 33, and 33a. 

► If the practice billing type is set to “Person”, billing info from Persons and Institutions | Providers will be used to populate Box 25, 33, and 33a.

Box 26

Box 26 Description: This box indicates the patient’s account number assigned by the provider’s accounting system. 

► This information is indicated within Valant as the Patient ID.

Box 27 Description: This box indicates whether the provider accepts assignment of Medicare benefits. 

► This information is indicated within Valant within Persons and Institutions | Patients | Insurance tab | Accept assignment box. This box is always checked if participating physician agrees to accept the negotiated rate as payment in full. Unchecked if the practice provides courtesy billing after receiving payment in full from the patient. For more information, please review the Billing Reference Guide. 

Box 28 

Box 28 Description: Total charges for billed services

►

Box 29

Box 29 Description: Total amount the patient paid.

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Box 30

Box 30 Description: 

► This box is not indicated within Valant. 

Box 31

 Box 31 Description: A signature on file indicates that the insurance company is authorized to pay the clinic directly.

►This information is automatically filled in when the “Signature on File box” is completed within the Patient Demographics tab. The Patient Demographics Tabs can be located in Persons and Institutions | Patients | Demographics | Signature on file box. 

 For more information regarding Patient Demographics information review the Patients Demographics Overview article.

Box 32

Box 32 Description: Box 32 refers to the name and address, and ZIP code of the facility where the services where rendered. Box 32a refers to the NPI for the service facility. Box 32b refers to the “Service Location Identifier” references the unique ID number for the facility other than the NPI. 

► The information for Box 32 is indicated by which facility was selected for that date-of-service when the charge was created within Tools | Scheduler | Appointments or Billing | Create Charge | Create Charge

► The information for Box 32a is listed within Valant within Persons and Institutions | Facilities | Facility NPI. 

► The information for Box 32b is listed within Valant within Persons and Institutions | Facilities | Service Location Identifier. 

Box 33

Box 33 Description: The billing provider’s billing name, address, ZIP code, and telephone number. Box 33a refers to the NPI of the billing provider or group. Box 33b is generally not reported but may include the group legacy ID field. 

► The billing provider info is indicated within Valant according to the “Practice Type” settings within Persons and Institutions | Practice | Billing Info | Practice Type

The Billing Info tab shows billing information for the Practice that will populate Box 33 of CMS 1500 form. This information should reflect how the practice is credentialed with insurance companies. 

► If the practice billing type is set to “Person”, billing info from Persons and Institutions | Providers will be used to populate Box 25, 33, and 33a

If practice billing type is set to “Non-Person”, billing info from Persons and Institutions | Practice will be used to populate Box 25, 33, and 33a. 

► If a group legacy ID is entered for the practice, this information will populate in Box 33b. The group legacy ID can be indicated within Persons and Institutions | Insurance Companies | Group Legacy ID

For more information on entering the practice billing information, please review “Billing Info for Practice”