AngelTrack CMS-1500 Crosswalk

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 auth signature
13	Insured's or Authorized Person's Signature	2300	"SIGNATURE ON FILE" if the PCR has captured an auth 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	[Left blank]
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

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