CMS-1500 Claim Form Therabill Support Specialist March 05, 2024 18:18 Updated Follow Resource of article links for different boxes on the CMS-1500 Claim Form. Patient & Insured Information Provider Information Box 1 - Plan Type Box 14 - Date of Current Illness, Injury, or Pregnancy Box 1a - Insured's I.D. Number Box 15 - Other Date Box 2 - Patient's Name Box 16 - Dates Patient Unable to Work in Current Occupation Box 3 - Patient's Birth Date, Sex Box 17 - Name of Referring Provider or Other Source Box 4 - Insured's Name Box 17a - Other ID# Box 5 - Patient's Address (multiple fields) Box 17b - NPI # Box 6 - Patient Relationship to Insured Box 18 - Hospitalization Dates Related to Current Services Box 7 - Insured's Address (multiple fields) Box 19 - Additional Claim Information (Designated by NUCC) Box 8 - Reserved for NUCC Use Box 20 - Outside Lab? / $ Charges Box 9 - Other Insured's Name Box 21 - Diagnosis or Nature of Illness or Injury Box 9a - Other Insured's Policy or Group Number Box 22 - Resubmission Code / Original Ref. No. Box 9b - Reserved for NUCC Use Box 23 - Prior Authorization Number Box 9c - Reserved for NUCC Use Section 24 - Service Lines Box 9d - Insurance Plan Name or Program Name Box 25 - Federal Tax ID Number Box 10a, 10b, & 10c - Is Patient's Condition Related To: Box 26 - Patient's Account No. Box 10d - Claim Codes Box 27 - Accept Assignment? Box 11 - Insured's Policy, Group, or FECA Number Box 28 - Total Charge Box 11a - Insured's Date of Birth, Sex Box 29 - Amount Paid Box 11b - Other Claim ID Box 30 - Reserved for NUCC Use Box 11c - Insurance Plan Name or Program Name Box 31 - Signature of Physician or Supplier Including Degrees or Credentials Box 11d - Is there another Health Benefit Plan? Box 32 - Service Facility Location Information Box 12 - Patient's or Authorized Person's Signature Box 32a - NPI# Box 13 - Insured's or Authorized Person's Signature Box 32b - Other ID# Box 33 - Billing Provider Info & Ph# Box 33a - NPI# Box 33b - Other ID# Related articles Section 24 - Service Lines Box 22 Resubmission Code/Original Ref. No. Box 31 - Signature of Physician or Supplier Including Degrees or Credentials Box 32 - Service Facility Location Information How to Read an EDI (837) File - Overview Comments 0 comments Article is closed for comments.
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