User Guide — CMS-1500 Form Reference

CMS_1500 Carrier (payer) address that is printed on the top of the form:

Field description: This box contains the carrier's (payer's) mailing address. The carrier is the insurance company that will adjudicate the claim.

Contact the CSC by selecting Support > Create Case or Call in the Main Menu to update this information.

1: MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER

Field Description: - These checkboxes identify the type of health insurance coverage applicable to this claim. This checkbox is populated according to the insurance package selection.  

Contact the CSC by selecting Support > Create Case or Call in the Main Menuto update this information.

1a: INSURED'S I.D. NUMBER

Field Description: This box contains the patient's Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer. This is a required field.

athenaOne location: Update Policy Details page: Member ID/certification number field (can be accessed via a link on the Quickview page)

2: PATIENT'S NAME

Field Description: This box contains the patient's last name, first name, and middle initial, if any, as shown on the patient's Medicare card. This is a required field.

athenaOne location: Quickview page: Legal last name; Legal first name; Middle name, suffix fields.

3: PATIENT'S BIRTH DATE

Field Description: This box contains the patient's 8-digit birth date (MM | DD | CCYY) and sex.athenaOne location: Quickview page: DOB field and Sex field.

4: INSURED'S NAME

Field Description: If there is insurance primary to Medicare, either through the patient's or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME. If Medicare is primary, leave blank.athenaOne location: Update Policy Details (Policy Holder section): Last name; First name; Middle name, suffix fields.

5: PATIENT'S ADDRESS

Field Description: This box contains the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and phone number.athenaOne location: Quickview: Address,Address (ctd), City, State, Zip,and Home phone fields.

6: PATIENT RELATIONSHIP TO INSURED

Field Description: Check the appropriate box for patient's relationship to insured when item 4 is completed.

athenaOne location: Update Policy Details (Policy Holder information): Patient's Relationship to Policy Holder field.

7: INSURED'S ADDRESS

Field Description: This box contains the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this item only when items 4, 6, and 11 are completed.athenaOne location: Update Policy Details (Policy Holder section): Address; Address (ctd), City, State, and Zip fields.

8: PATIENT STATUS

Field Description: Check the appropriate box for the patient's marital status and whether employed or a student.

athenaOne location: Quickview: Marital status field.

9: OTHER INSURED'S NAME (boxes 9 a — d contain information about the other policy holder, if there is more than one insurance policy covering the medical visit)

Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.

Note: Only participating physicians and suppliers are to complete item 9 and its subdivisions and only when the beneficiary wishes to assign his/her benefits under a MEDIGAP policy to the participating physician or supplier.

Participating physicians and suppliers must enter information required in item 9 and its subdivisions if requested by the beneficiary. Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer.

Field Description: This box contains the name of the policy holder for the secondary (or other) insurance populated and is sent to the payer as requested.

athenaOne location: Update Policy Details (Policy Holder section): Address; Address (ctd) fields.

9a: OTHER INSURED'S POLICY OR GROUP NUMBER

Field Description: This box contains the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.

athenaOne location: Update Policy Details (Policy Information): Policy/Group Number field.

9b: OTHER INSURED'S DATE OF BIRTH SEX

Field Description: This box contains the Medigap insured's 8-digit birth date (MM | DD | CCYY) and sex.

athenaOne location: Update Policy Details (Policy Holder section): DOB, Sex fields.

9c: EMPLOYER'S NAME OR SCHOOL'S NAME

Field Description: Leave blank if a Medigap PayerID is entered in item 9d. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and ZIP code copied from the Medigap insured's Medigap identification card.

athenaOne location: Update Policy Details page (Policy Holder section): Employer, Employers Address

9d: INSURANCE PLAN NAME OR PROGRAM NAME

Field Description: The 9-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then enter the Medigap insurance program or plan name. 

If the beneficiary wants Medicare payment data forwarded to a Medigap insurer through the Medigap claim-based crossover process, the participating provider of service or supplier must accurately complete all of the information in items 9, 9a, 9b, and 9d.

Contact the CSC by selecting Support > Create Case or Call in the Main Menu to update this information.

10: IS PATIENT'S CONDITION RELATED TO:

Field Description: These boxes contain information regarding whether employment, auto liability or other accident involvement applies to one or more of the services described in box 24.

athenaOne location: Claim Edit page: (Patient's condition related to) options

(advanced view) Charge Entry page: Patient's condition related to options

10d: RESERVED FOR LOCAL USE

Field Description: payer–defined usage. Populated via the athenaOne Rules Engine.

11: INSURED'S POLICY OR FECA NUMBER

Field Description: This box contains the insured's (policy holder's) policy or group number.  

athenaOne location: Update Policy Details page: (Policy Holder section): Policy/Group

Number field.

11a: INSURED'S DATE OF BIRTH / SEX

Field Description: This box contains the insured's 8-digit birth date (MM | DD | CCYY) and sex.

athenaOne location: Update Policy Details page: (Policy Holder section): DOB and Sex fields.

11b: EMPLOYERS NAME OR SCHOOL NAME

Field Description: This box contains the employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word "RETIRED."

athenaOne location: Update Policy Details page: (Policy Holder section): Employer

11c: INSURANCE PLAN OR PROGRAM NAME

Field Description: This box contains the 9-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer's program or plan name. If the primary payer's EOB does not contain the claims processing address, record the primary payer's claims processing address directly on the EOB. This is required if there is insurance primary to Medicare that is indicated in item 11.athenaOne location: Claim Edit page: Primary payer (or Secondary payer) menu.

(advanced view) Charge Entry page: Primary payer menu

11d: IS THERE ANOTHER HEALTH BENEFIT PLAN?

Field Description: Indicates that the patient has a secondary insurance policy

athenaOne location: Quickview page under the Insurances section: If the Secondary field information is present, the YES box is checked. If the patient does not have a secondary policy (the add secondary link is visible), then the NO box is checked.

12: PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE

Field Description: This box contains "SIGNATURE ON FILE" if the athenaOne Release of Information checkbox is checked for this patient. The date defaults to the billed date of the claim on all claim submissions in athenaOne.

athenaOne location: Claim Edit page: Release of Information checkbox

(advanced view) Charge Entry page: Signature on File for Release of Information checkbox

Administered via the Privacy Information page: Patient Signature on File for Release of Billing Information? checkbox and date fields.

Also appears on Quickview page: Release of Info on File checkbox

Note: The Notice Given, Release of Info on File, and Assignment of Benefits on File checkboxes may be combined into one or two privacy checkboxes on the Quickview page. The number of checkboxes that appear depends on the "Number of Patient Privacy Checkboxes" practice setting. Contact the CSC by selecting Support > Create Case or Call in the Main Menu to change this setting for your practice.

13: INSURED'S OR AUTHORIZED PERSON'S SIGNATURE

Field Description: This box will contain "SIGNATURE ON FILE" if the athenaOne Assignment of Benefits checkbox is checked for this patient.

athenaOne location: Claim Edit page: Assignment of Benefits checkbox (advanced view) Charge Entry page: Signature on File for Assignment of Benefits checkbox  

Administered via the Privacy Information page: Insured Signature on File for Assignment of Benefits? checkbox

Also appears on Quickview page: Assignment of Benefits on File checkbox.

Note: The Notice Given, Release of Info on File, and Assignment of Benefits on File checkboxes may be combined into one or two privacy checkboxes on the Quickview page. The number of checkboxes that appear depends on the "Number of Patient Privacy Checkboxes" practice setting. Contact the CSC by selecting Support > Create Case or Call in the Main Menu to change this setting for your practice.

14: DATE OF CURRENT:

Field Description: This box contains the either an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of current illness, injury, or pregnancy.

athenaOne location: Claim Edit page: Current illness date field.

(advanced view) Charge Entry page: Current illness date field.

15: IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE

Field Description: This box contains an 8-digit (MM | DD | CCYY) date of same or similar illness.

athenaOne location: Claim Edit page: Same or similar illness date field.

(advanced view) Charge Entry page: Same or similar illness date field.

16: DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

Field Description: If the patient is employed and is unable to work in current occupation, this box contains an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when patient is unable to work. An entry in this field may indicate employment related insurance coverage.

athenaOne location: Claim Edit page: Patient unable to work date fields.

(advanced view) Charge Entry page: Patient unable to work date fields.

17: NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

Field Description: This box contains the name of the referring or ordering physician if the service or item was ordered or referred by a physician.

Referring physician — physician who requests an item or service for the beneficiary for which payment may be made by the patient's insurance.

Ordering physician —  physician (or non-physician practitioner) who orders non-physician services for the patient. Examples: diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incidental to the ordering physician's or non-physician practitioner's service.

athenaOne location: Claim Edit page: Referring Provider choose/view tool / field.

Charge Entry page: Referring Provider choose/view tool / field.

17a: I.D. NUMBER OF REFERRING PHYSICIAN

Field Description: This box contains the referring physician's provider ID number. Required when a service was ordered or referred by a physician (see item 17). The shaded area accommodates other ID numbers.

athenaOne location: Referring Provider Numbers page: (use the Show Referring Provider Numbers Filter button to locate the referring provider; the number is shown in the provider # column)

17b:

Field Description: Two vertical lines appear to accommodate the NPI number.

18: HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

Field Description: This box contains 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.  

athenaOne location: Claim Edit page: Hospitalization dates fields.

(advanced view) Charge Entry page: Hospitalization dates fields.

19: RESERVED FOR LOCAL USE

Field Description: This field may have information auto-populated into it based on formatting rules.

athenaOne location: There is a related field on the Claim Edit page: Reserved (19) (remarks). The contents of the Line note field (on each procedure line) for payer-requested information may also populate this field, depending on payer-specific formatting.

Important Note: The Claim Edit page: the data in the Additional HCFA Free Text: field does not populate box 19.

(advanced view) Charge Entry page: the data in the Additional HCFA Free Text field does not populate box 19.

20: OUTSIDE LAB?

Field Description: This box contains information about whether an entity other than the billing entity performed the diagnostic test. If the lab performing the testing is under the same tax ID as the supervising provider, this box should be blank. This field will auto-populate when the modifier –90 is used on a lab test.

21: DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line)

Field Description: This box contains the patient's diagnosis/condition. Usually, all physician and non-physician specialties (i.e., PA, NP, CNS, CRNA) use an ICD-9-CM code and code to the highest level of specificity. Enter up to four codes in priority order (primary, secondary condition).

athenaOne location: Claim Edit page: Diagnoses text boxes

Charge Entry page: Diagnoses Justifying this Procedure text boxes

22: MEDICAID RESUBMISSION CODE  

Field Description: Many Medicaid payers (and some non-Medicaid payers) may require special codes when claims are resubmitted. These codes relate to their payer grids — numbers which correlate to the original claim. There are two data components:

• CODE: Typically indicates type of resubmission, such as reconsideration, adjustment, or void; specific use varies by Medicaid.
• ORIGINAL REF. NO.: Typically indicates the payer's internal control number (ICN) or claim reference number (CRN) for the resubmitted claim; specific use varies by Medicaid.

Note: Claim Edit page: Resubmission field.

23: PRIOR AUTHORIZATION NUMBER/CLIA NUMBER

Field Description: This box usually contains the prior authorization number that the client received from the payer before the services are rendered, or the CLIA number associated with the claim facility or department. Other formatting requests from payers (primarily Medicare) are managed through Rules and Format Management.

athenaOne location: Claim Edit page: Authorization menu.

Charge Entry page: Authorization menu.

Department Numbers page: CLIA number.

24A: DATES OF SERVICE

Field Description: This box contains an 8-digit (MM | DD | CCYY) date for each procedure, service, or supply. Shaded area on the top portion of each line to be used for reporting supplemental information.

Note for anesthesia claims: The top part of CMS-1500 Box 24 contains anesthesia start/end times.

athenaOne location: Claim Edit page: From, To date fields.

Charge Entry page: From, To date fields.

24B: PLACE OF SERVICE

Field Description: This box contains the appropriate place of service type codes for the department where the services have been rendered.

Shaded area on the top portion of each line to be used for reporting supplemental information.

athenaOne location: Claim Edit page: Facility menu.

Charge Entry page: Service department menu.

Departments page: Place of service type menu (click the update link next to the department to view the selected to view the selected place of service type code. The actual code is in [brackets]

24C: EMG

Field Description: This box contains emergency service information.

Shaded area on the top portion of each line to be used for reporting supplemental information.

athenaOne location: Claim Edit page: EMG flag checkbox (on the charge line)

(advanced view) Charge Entry page: EMG checkbox

24D: PROCEDURES, SERVICES, OR SUPPLIES

Field Description: This box contains the procedures, services, or supplies using the AMA Current Procedural Terminology (CPT) or CMS health care Common Procedure Coding System (HCPCS) code. It also contains a box for any modifiers to be considered with each CPT/ HCPCS code.

Shaded area on the top portion of each line to be used for reporting supplemental information.

athenaOne location: Claim Edit page: CPT text box

Charge Entry page: Procedure text boxes

24E: DIAGNOSIS POINTER

Field Description: This box contains the diagnosis code reference number ("pointer") as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, this box will be populated with the primary reference number ("pointer") for each service: a 1, or a 2, or a 3, or a 4.

Shaded area on the top portion of each line to be used for reporting supplemental information.

athenaOne location: Claim Edit page: D1, D2 text box  

Charge Entry page: Diagnoses Justifying this Procedure text box

24F: $ CHARGES

Field Description: This box contains the charge for each listed service.

HIPAA Compliance note: Medicare regulations are read by the government to require a "most favored nations" treatment for Medicare. Under this approach, if the provider lowers a charge to another payer it also has to lower the charge to Medicare.  

athenaOne location: Claim Edit page: $/unit.

(advanced view) Charge Entry page: Units text boxes

This information originates from the Fee Schedule page (click the edit procedure fees link for the fee schedule, use the buttons to display the procedure codes you want, then click update to access the procedure code).

24G: DAYS OR UNITS

Field Description: This box contains number of days or units. Defaults to 1. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. This field should contain at least one day or unit.

athenaOne location: Claim Edit page: U text boxes field. 

(advanced view) Charge Entry page: Units field.

24H: EPSDT Family Plan

Field Description: This box contains information about the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program for many payers, especially Medicaids.

athenaOne location: Claim Edit page: EPSDT flag checkbox (on the charge line).

(advanced view) Charge Entry page: EPSDT checkbox.

24I: ID. QUAL.

Field Description: If additional provider numbers/identifiers are being sent in 24J, the qualifier appears here.

athenaOne location: Auto-populated by athenaOne based on the additional identification being sent.

Common qualifiers:

0B – State license number

1B – Blue Shield provider number

1C – Medicare provider number

1D – Medicaid provider number

1G – Provider UPIN number

1H – CHAMPUS identification number

EI – Employer's identification number

G2 – Provider commercial number

LU – Location number

N5 – Provider plan network identification number

SY – Social Security number (The Social Security number may not be used for Medicare)

X5 – State industrial accident provider number

ZZ – Provider taxonomy – A list of the valid Taxonomy codes

24J RENDERING PROVIDER ID. #

Field Description: The supervising provider's NPI number is reported in the unshaded field. The Legacy Number of the individual provider, the taxonomy code, or another ID number can be reported in the shaded field when applicable.

athenaOne location: NPIs and Other Numbers page (select NPI Number from the Category menu to see NPI numbers for providers).

The Legacy Number is populated when a number is entered for an individual provider on the Payer Enrollment page (the legacy number is not available for all enrollment categories, and is populated on claims only when required by the payer). The taxonomy code is populated from the Providers page unless it is overridden on the Payer Enrollment page for the provider.

25: FEDERAL TAX I.D. NUMBER SSN / EIN

Field Description: This box contains the Federal Tax ID of the supervising provider's Medical Group.

athenaOne location: Medical Groups page: Federal ID Number field.

Note: For providers who bill as individuals, refer to the Payer Enrollment page: Bill as an Individual? checkbox.

If a provider is credentialed as an individual, the SSN is populated from the Payer Enrollment page. When editing the Billing Group in the advanced view of the Payer Enrollment page and setting specific billing situations (for a single provider), select the Provider bills with SSN? option in the Individual billing field under the "Billing Information" heading.

26: PATIENT'S ACCOUNT NO.

Field Description: This box contains the claim ID number as assigned by athenaOne.

athenaOne location: Claim Edit page (at the top), "v", context (or client) ID.

27: ACCEPT ASSIGNMENT?

Field Description: This box contains the information as to whether the supervising provider accepts assignment of payer's benefits. The athenaOne default behavior is "yes."

Contact the CSC by selecting Support > Create Case or Call in the Main Menu to change the default behavior.

athenaOne location: Claim Edit page: Primary accepts assignment or Secondary accepts assignment menu.

(advanced view) Charge Entry page: Primary accepts assignment menu.

28: TOTAL CHARGE

Field Description: This box contains the total charges for the services (i.e., total of all charges in item 24f).

athenaOne location: Auto-populated by athenaOne based on the amounts that appear in 24f.

29: AMOUNT PAID

Field Description: This is the amount that has already been paid and adjusted for this claim. If this is a primary claim, this amount is $0 or blank. If this is a secondary claim, this field contains the amount that was paid and adjusted by the primary insurance.

athenaOne location: Claim Edit page: Ins1 column (column is located under the show voided Transactions & full audit history link at the right side of the page).

30: BALANCE DUE

Field Description: This box is the amount transferred to the next payer responsibility.

athenaOne location: N/A.

31: SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS

Field Description: This box contains the printed name and credentials of the supervising provider, the signature of the supervising provider or supplier or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY) that the form was printed/signed. The default for this box is the supervising provider's printed name.

athenaOne location: Claim Edit page and the (advanced view) Charge Entry page: the selected Supervising provider. This provider's printed name is found on the Providers page, in the Billed name field. If an actual signature is required, athenahealth or the practice signs these claims.

32: SERVICE FACILITY LOCATION INFORMATION

Field Description: This box contains the name, address, and ZIP code of the facility where services were furnished. This address can be a hospital, clinic, laboratory, or physician's office.

athenaOne location: Based on the selection on the Claim Edit page (Facility menu) and the Charge Entry page (Service department menu). This information originates from the Departments page (Billing name and Address fields).

32a.

Field Description: This box accommodates reporting of the Type II NPI number and is indicated by the shaded label of "NPI." This shaded portion accommodates the reporting of other ID numbers.

athenaOne location: Department Numbers page, department number (supplied by the payer or credentialing entity) in the Number field.

32b.

Field Description: This shaded field accommodates the reporting of other ID numbers.

33: BILLING PROVIDER INFO & PH #

Field Description: This box contains the supervising provider's Medical Group name, address, ZIP code, and telephone number. This is also known as the Pay-To address: the address where remittance is to be sent. Parentheses after the title indicate the location for reporting the telephone number.

athenaOne location: Pay-To Address Admin page: Addressee fields

33a.

Field Description: This box contains the medical group's NPI number.

athenaOne location: NPIs and Other Numbers page, unless the number is overridden on the Payer Enrollment page. If you need to add an individual provider NPI on the Payer Enrollment page, edit an existing billing group or add a new billing group for the payer (you may need to review the enrollment category of the insurance package). On the Advanced view of the Payer Enrollment page, deselect the use group default? option and then enter the individual provider's NPI in the Billing NPI field.

33b. Medical Group Number (Legacy or Other number)

Field Description: This box accommodates the reporting of other ID numbers.

Note: In athenaOne, a provider can belong to only one medical group. Due to a past merger or restructuring of medical groups, a provider number may be listed with a "medical group override number" to be used on claims in place of the provider's medical group number.

athenaOne location: Medical Groups page: Number column.

NPIs and Other Numbers page: Group# Override field.

The legacy or other number is populated from the legacy number field for the medical group on the Payer Enrollment page (this field is not available for all enrollment categories). To add a package-specific number, create a new billing group on the Payer Enrollment page for the corresponding enrollment category and apply it only to specific billing situations for an insurance package. Enter that package number and the Medical Group legacy number as needed.