Updating Professional CMS-1500 Claim Forms (Box 1-33)

Box 1 - Plan Type

Box 1a - Insured's ID Number

Box 2 - Patient's Name

Box 3 - Patient's Birthdate, Sex

Box 4 - Insured's Name

Box 5 - Patient's Address

Box 6 - Patient Relationship to Insured

Box 7 - Insured's Address

Box 8 - Reserved for Use by the NUCC

Box 9 - Other Insured's Name

Box 9a - Other Insured’s Policy or Group Number

Box 9b - Reserved for NUCC Use

Box 9c - Reserved for NUCC Use

Box 9d - Insurance Plan Name or Program Name

Box 10a, 10b, 10c - Is Patients Condition Related To:

Box 10d - Claim Codes

Box 11 - Insured's Policy, Group, or FECA Number

Box 11a - Insured's Date of Birth, Sex

Box 11b - Other Claim ID

Box 11c - Insurance Plan Name or Program Name

Box 11d - Is there another Health Benefit Plan?

Box 12 - Patient's or Authorized Person's Signature

Box 13 - Insured's or Authorized Person's Signature

Box 14 - Date of Current Illness, Injury or Pregnancy

Box 15 - Other Date

Box 16 - Dates Patient Unable to Work in Current Occupation

Box 17 - Name of Referring Provider or Other Source

Box 17a - Other ID#

Box 17b - Referring Provider NPI #

Box 18 - Hospitalization Dates Related to Current Services

Box 19 - Additional Claim Information (Designated by NUCC)

Box 20 - Outside Lab Charges, $ Charges

Box 21 - Diagnosis or Nature of Illness or Injury

Box 22 - Resubmission Code/Original Ref. Number

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 Suppliers

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 Number

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 and Ph#

Box 33a - NPI #

Box 33b - Other ID#