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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