Coding, Claims, and Clearinghouse
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      CMS-1500 Crosswalk Document for AngelTrack

      A side-by-side field-by-field breakdown of all of the fields on a CMS-1500 form and where they can be found in AngelTrack

      This crosswalk shows how all of the boxes on a CMS-1500 form are populated from AngelTrack data. If you can't figure out how to get AngelTrack to populate a certain box, this is the place to look.


      Box Description X12.837 Loop Source of Data in AngelTrack
      - Mailing Address (top right corner)   Patient insurance settings: Locked insurance payor ID record
      1 Type of Insurance 2000B Patient insurance settings
      1A Insured's ID Number 2010BA Patient insurance settings: ID number
      2 Patient's Name 2010CA Patient record
      3 Patient's Birth Date, Sex 2010CA Patient record
      4 Insured's Name 2010BA Patient record if policyholder is self, else
      Patient insurance settings
      5 Patient's Address 2010CA Patient record
      6 Patient Relationship to Insured 2000B Patient insurance settings
      7 Insured's Address 2010BA Patient record
      8 Reserved   [Left blank]
      9 Other Insured's Name 2320A "SAME" if policyholder is self, else
      Patient insurance settings
      9A Other Insured's Policy or Group Number 2320 Patient insurance settings: ID number
      9B Reserved   [Left blank]
      9C Reserved   [Left blank]
      9D Insurance Plan Name or Program Name 2320 Patient insurance settings: Company or provider name
      10A Is Patient's Condition Related to Employment 2300 PCR Injury: "Is work-related" field; can override in Coding
      10B Is Patient's Condition Related to Auto Accident 2300 PCR Injury: Primary cause; can override in Coding
      Note: Each injury cause ICD-10 from PCR Injury may be flagged as AA, AP, or OA. You can adjust these flags from the Injury Cause List under Settings.
      10C Is Patient's Condition Related to Other Accident 2300 PCR Injury: Primary cause; can override in Coding
      Note: Each injury cause ICD-10 from PCR Injury may be flagged as AA, AP, or OA. You can adjust these flags from the Injury Cause List under Settings.
      10D Reserved   [Left blank]
      11 Insured's Policy, Group, or FECA Number 2000B Patient insurance settings: Group or policy number
      11A Insured's Date of Birth, Sex 2010BA Patient record if policyholder is self, else
      Patient insurance settings
      11B Reserved

      		[Left blank]
      11C Insurance Plan Name or Program Name 2000B [Left blank]
      11D Is there another health benefit plan?   Patient insurance settings
      12 Patient's or Authorized Person's Signature 2300 "SIGNATURE ON FILE" if the PCR has captured an authorization signature
      13 Insured's or Authorized Person's Signature 2300 "SIGNATURE ON FILE" if the PCR has captured an authorization signature
      14 Date of Current Illness, Injury, Pregnancy 2300 "Accident" or "Symptoms" date from Coding, if any
      14 Date Qualifier 2300 "439" if there is an "Accident" date specified in Coding (see note), or
      "431" if there is a "Symptoms" date specified in Coding, else
      [Left blank]
      Note: The Coding page will insist on an "Accident" date, and emit 439 rather than 431, if the "Cause of Injury" from PCR Injury is an ICD-10 that is flagged as AA, AP, or OA. You can adjust these flags from the Injury Cause List under Settings.
      15 Other Date Qualifier 2300 "454" ("Date of service")
      15 Other Date 2300 Followup: Date/Time Transport Began, if any, else Dispatch Edit: Date/Time Activated
      16 Dates Patient is Unable to Work in Current Occupation 2300 [Left blank]
      17 Name of Referring Provider 2310A Coding: Referred by; data is drawn from Followup: Referring Physician
      17A Referring Other ID Qualifier 2310A [Left blank]
      17A Referring Other ID 2310A [Left blank]
      17B Referring NPI 2310A Coding: Referred by NPI; data is drawn from Followup: Referring Physician NPI
      18 Hospitalization Dates Related to Current Services 2300 "Admission" date from Coding, if any; data is drawn from PCR Hospital
      "Discharge" date from Coding, if any
      19 Additional Claim Information 2300 Followup or Coding: Reason for Stretcher
      20 Outside Lab Charges 2400 [Left blank]
      21 Diagnosis Codes 2300 Coding: Diagnosis codes
      21 ICD Indicator 2300 "0" (ICD-10) after 2015-10-01, else "9" (ICD-9)
      22 Resubmission and/or Original Reference Number   "7" plus the original reference number, if the claim is marked as "Refile"/"Replacement" on the Coding page and if a payor control number has already been received for the original claim.
      23 Prior Authorization Number 2300 Coding: Prior authorization number, plus
      The origin ZIP code, if the claim is for Medicare or if the locked insurance payor ID is configured to require it in this box
      24A Date of Service 2400 Followup: Date/Time Transport Began, if any, else
      Dispatch Edit: Date/Time Activated
      24B Place of Service 2400 "41" if ground unit, "42" if air unit
      24C EMG   "X" if emergent
      24D Procedure Codes 2400 Coding: Procedure codes
      24E Diagnosis Pointer 2400 Coding: Diagnosis codes
      24F Charges 2400 Pricing, or Coding if custom priced
      24G Days or Units Billed 2400 Coding: Procedure quantities
      24H EPSDT/Family Plan   [Left blank]
      24I Rendering Provider ID Qualifier   'XX' if the locked insurance payor ID is configured to require the rendering provider taxonomy code in this box
      24J Rendering Provider ID   Rendering provider taxonomy code (configured under Billing Configuraton) if the locked insurance payor ID is configured to require it in this box
      24J Rendering Provider NPI 2310B Billing Configuration
      25 Federal Tax ID or SSN 2010AA Billing Configuraton
      26 Patient's Account Number 2300 AngelTrack claim ID (ADxxxxxxN1)
      27 Accept Assignment? 2300 Coding: Reassignment of Benefits radiobutton
      28 Total Charges 2300 Pricing, or Coding if custom priced
      29 Amount Paid 2300
      2320      		 Prior payment event records
      30 Reserved   [Left blank]
      31 Signature of Physician 2300 Business Information: Rendering Provider Name;
      Date the 1500 was generated
      32 Service Facility Location 2310E
      2310F      		 Dispatch Edit: Origin address, and
      Dispatch Edit: Destination address, if any
      Note: Each address will be formatted on three lines of text, rather than on two, if the locked insurance payor ID is configured to require it.
      32A Service Facility NPI 2310C Facility Edit: NPIs (first entry)
      from the facility record attached to the dispatch, if the coding page specifies a "Service facility" option
      32B Service Facility Other ID   [Left blank]
      33 Billing Provider Info and Phone 2010AA Billing Configuraton
      33A Billing Provider NPI 2010AA Billing Configuraton
      33B Billing Provider Other ID   Coding: Alternate ID, if any is specified; else
      'XX' plus the billing provider taxonomy code (configured under Billing Configuration) if the locked insurance payor ID is configured to require it in this box