CMS-1500 form boxes
The CMS-1500 (also called the 1500 form) is the standardized form healthcare providers and billing companies in the United States use to submit claims to insurance companies for processing. It has 33 boxes, along with several sub-boxes.
58 boxes and sub-boxes
Patient and insured information Boxes 1–13
- 1
- Type of Health Insurance Coverage
- 1a
- 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
- 9a
- Other Insured’s Policy or Group Number
- 9b
- Reserved for NUCC Use
- 9c
- Reserved for NUCC Use
- 9d
- Insurance Plan Name or Program Name
- 10
- Patient’s Condition Related To
- 10a
- Is Condition Employment Related?
- 10b
- Is Condition Auto Accident Related?
- 10c
- Is Condition Other Accident Related?
- 10d
- Claim Codes (Designated by NUCC)
- 11
- Insured’s Policy, Group, or FECA Number
- 11a
- Insured’s Date of Birth and Sex
- 11b
- Other Claim ID (Designated by NUCC)
- 11c
- Insurance Plan Name or Program Name
- 11d
- Is There Another Health Benefit Plan?
- 12
- Patient’s or Authorized Person’s Signature
- 13
- Insured’s or Authorized Person’s Signature
Dates, referral and claim information Boxes 14–19
- 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
- 17a
- Other ID#
- 17b
- NPI#
- 18
- Hospitalization Dates Related to Current Services
- 19
- Additional Claim Information (Designated by NUCC)
Lab, diagnosis and authorization Boxes 20–23
- 20
- Outside Lab? / $ Charges
- 21
- Diagnosis Code or Nature of Illness or Injury
- 22
- Resubmission Code / Original Reference Number
- 23
- Prior Authorization Number
Service line information Box 24
- 24
- Service Line Information
- 24a
- Date(s) of Service
- 24b
- Place of Service
- 24c
- Emergency Indicator
- 24d
- Procedures, Services, or Supplies (CPT & modifier)
- 24e
- Diagnosis Pointer
- 24f
- Charges
- 24g
- Days or Units
- 24h
- EPSDT / Family Plan
- 24i
- ID Qualifier (e.g., NPI)
- 24j
- Rendering Provider Information
Billing and provider information Boxes 25–33
- 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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Boxes 8, 9b, 9c and 30 are reserved for NUCC use.
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