CMS-1500 Boxes
The 1500 form, also called the CMS-1500 form, is a standardized form used by healthcare providers and medical billing companies in the United States to submit claims to insurance companies for processing.
This form contains 33 boxes, along with several sub-boxes.
| BOX # | DATA |
| 1 | Type of Health Insurance Coverage |
| 1 a | Insured’s ID Number |
| 2 | Patient’s Name |
| 3 | Patient’s Birth Date and Sex |
| 4 | Insured’s Name |
| 5 | Patient’s Address |
| 6 | Patient Relationship to Insured |
| 7 | Insured’s Address |
| 8 | Reserved for NUCC Use |
| 9 | Other Insured’s Name |
| 9 a | Other Insured’s Policy or Group Number |
| 9 b | Reserved for NUCC Use |
| 9 c | Reserved for NUCC Use |
| 9 d | Insurance Plan Name or Program Name |
| 10 | Patient’s Condition Related To |
| 10 a | Is Condition Employment Related? |
| 10 b | Is Condition Auto Accident Related? |
| 10 c | Is Condition Other Accident Related? |
| 10 d | Claim Codes (Designated by NUCC) |
| 11 | Insured’s Policy, Group, or FECA Number |
| 11 a | Insured’s Date of Birth and Sex |
| 11 b | Other Claim ID (Designated by NUCC) |
| 11 c | Insurance Plan Name or Program Name |
| 11 d | Is There Another Health Benefit Plan? |
| 12 | Patient’s or Authorized Person’s Signature |
| 13 | Insured’s or Authorized Person’s Signature |
| 14 | Date of Current Illness, Injury, or Pregnancy |
| 15 | Other Date |
| 16 | Dates Patient Unable to Work in Current Occupation |
| 17 | Name of Referring Provider or Other Source |
| 17 a | Other ID# |
| 17 b | NPI# |
| 18 | Hospitalization Dates Related to Current Services |
| 19 | Additional Claim Information (Designated by NUCC) |
| 20 | Outside Lab? / $ Charges |
| 21 | Diagnosis code or Nature of Illness or Injury |
| 22 | Resubmission Code / Original Reference Number |
| 23 | Prior Authorization Number |
| 24 | Service Line Information |
| 24 a | Date(s) of Service |
| 24 b | Place of Service |
| 24 c | Emergency Indicator |
| 24 d | Procedures, Services, or Supplies (CPT & modifier) |
| 24 e | Diagnosis Pointer |
| 24 f | Charges |
| 24 g | Days or Units |
| 24 h | EPSDT / Family Plan |
| 24 i | ID Qualifier (e.g., NPI) |
| 24 j | Rendering provider information |
| 25 | Federal Tax ID Number |
| 26 | Patient’s Account Number |
| 27 | Accept Assignment? |
| 28 | Total Charge |
| 29 | Amount Paid |
| 30 | Reserved for NUCC Use |
| 31 | Signature of Physician or Supplier Including Degrees or Credentials |
| 32 | Service Facility Location Information |
| 33 | Billing Provider Info & Phone Number |
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