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 |