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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 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