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 |
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- | Mailing Address (top right corner) |
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1 | Type of Insurance |
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1A | Insured's ID Number |
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2 | Patient's Name |
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3 | Patient's Birth Date, Sex |
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4 | Insured's Name |
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5 | Patient's Address |
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6 | Patient Relationship to Insured |
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7 | Insured's Address |
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8 | Reserved |
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9 | Other Insured's Name |
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9A | Other Insured's Policy or Group Number |
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9B | Reserved |
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9C | Reserved |
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9D | Insurance Plan Name or Program Name |
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10A | Is Patient's Condition Related to Employment |
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10B | Is Patient's Condition Related to Auto Accident |
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10C | Is Patient's Condition Related to Other Accident |
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10D | Reserved |
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11 | Insured's Policy, Group, or FECA Number |
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11A | Insured's Date of Birth, Sex |
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11B | Reserved |
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11C | Insurance Plan Name or Program Name |
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11D | Is there another health benefit plan? |
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12 | Patient's or Authorized Person's Signature |
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13 | Insured's or Authorized Person's Signature |
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14 | Date of Current Illness, Injury, Pregnancy |
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14 | Date Qualifier |
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15 | Other Date Qualifier |
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15 | Other Date |
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16 | Dates Patient is Unable to Work in Current Occupation |
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17 | Name of Referring Provider |
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17A | Referring Other ID Qualifier |
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17A | Referring Other ID |
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17B | Referring NPI |
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18 | Hospitalization Dates Related to Current Services |
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19 | Additional Claim Information |
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20 | Outside Lab Charges |
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21 | Diagnosis Codes |
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21 | ICD Indicator |
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22 | Resubmission and/or Original Reference Number |
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23 | Prior Authorization Number |
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24A | Date of Service |
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24B | Place of Service |
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24C | EMG |
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24D | Procedure Codes |
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24E | Diagnosis Pointer |
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24F | Charges |
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24G | Days or Units Billed |
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24H | EPSDT/Family Plan |
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24I | Rendering Provider ID Qualifier |
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24J | Rendering Provider ID |
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24J | Rendering Provider NPI |
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25 | Federal Tax ID or SSN |
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26 | Patient's Account Number |
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27 | Accept Assignment? |
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28 | Total Charges |
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29 | Amount Paid |
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30 | Reserved |
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31 | Signature of Physician |
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32 | Service Facility Location |
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32A | Service Facility NPI |
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32B | Service Facility Other ID |
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33 | Billing Provider Info and Phone |
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33A | Billing Provider NPI |
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33B | Billing Provider Other ID |
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