CMS-1500 Claim Form Instructions
Box by box description and Therabill mapping of the CMS-1500 Claim Form.
- Box 18 - Hospitalization Dates Related to Current Services
- Box 19 - Additional Claim Information (Designated by NUCC)
- Box 20 - Outside Lab? / $ Charges
- Box 21 - Diagnosis or Nature of Illness or Injury
- Box 22 Resubmission Code/Original Ref. No.
- Box 23 - Prior Authorization Number
- Section 24 - Service Lines
- Box 24a - Date(s) of Service
- Box 24b - Place of Service
- Box 24c - EMG
- Box 24d - Procedures, Services, or Supplies
- Box 24e - Diagnosis Pointer
- Box 24f - $ Charges
- Box 24g - Days or Units
- Box 24h - EPSDT/Family Plan
- Box 24i - ID Qualifier
- Box 24j - Rendering Provider
- Box 25 - Federal Tax ID Number
- Box 26 - Patient’s Account No.
- Box 27 - Accept Assignment?
- Box 28 - Total Charge
- Box 29 - Amount Paid
- Box 30 - Reserved for NUCC Use
- Box 31 - Signature of Physician or Supplier Including Degrees or Credentials
- Box 32 - Service Facility Location Information
- Box 32a - NPI#
- Box 32b - Other ID#
- Box 33 - Billing Provider Info & Ph#
- Box 33a - NPI#
- Box 33b - Other ID#