This guide explains how the fields in My Clients Plus populate the CMS 1500 claim form.
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Click here to see how to view the CMS 1500 form for the invoice.
Jump to Box 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
Carrier Block
Carrier block is filled with Insurance Organization's name and address from Insurer Details page.
Box 1
Current Insurer's Insurance Type from Insurer Details page.
Box 1a
Insured’s ID Number from Client's Bill To & Insurance Info page.
Box 2
Client's Name in format: Last Name, First Name, Middle Initial, e.g. "Doe, John, F"
Box 3
Client's DOB and Gender from Client Details page.
Box 4
Insured's name in format: Last Name, First Name, Middle Initial, e.g. "Doe, John, F".
- If Relationship to the Insured is "Self", then the data is taken from the Client Details page.
- Otherwise the data is taken from the "Info about insured" block on the Bill To & Insurance Info page.
Box 5
- Client's Address.
- Telephone is the first non-empty value of following fields:
- Phone from Bill To & Insurance Info page.
- Mobile Phone and Home Phone from Client Details page.
- In other words, if Bill To Phone is populated, the value is taken from there. If it's empty, then the value is taken from Mobile Phone from the Client Details page. If Mobile Phone is empty, then the value is taken from Home Phone from the Client Details page.
Box 6
Relationship to Insured from Bill To & Insurance Info page.
Box 7
Insured's address from Bill To & Insurance Info page.
If Relationship to Insured is "Self", then the data is taken from the Client Details page.
Otherwise the data is taken from the "Info about insured" block on the Bill To & Insurance Info page.
Box 8
Is not filled in My Clients Plus.
Box 9
“Other Insured's name”, “Other Insured's Policy or Group Number” and "Insurance Plan Name or Program Name" fields are taken from client's insurance that is not used for CMS1500 generation.
Value for “Other Insured's Policy or Group Number” is taken from "Policy or FECA Number" field in My Clients Plus and if it's empty, the value is taken from "Group Number" field.
If the secondary insurance is used for CMS1500 and it's type is Medicare, then this box is left blank.
Boxes 9.b and 9.c are not filled by My Clients Plus.
Box 10
On the Client's Bill to and Insurance info page there is a drop down that says: "Is Client's condition related to an accident?" with options No (default), Employment, Auto Accident, and Other Accident.
If anything besides the default is selected, users will be prompted to enter more information which will be used to populate Boxes 10A - 10C on the CMS 1500 Form. If No is selected then all flags will be marked to no.
Box 10.d is not filled by My Clients Plus.
Box 11
Box is filled depending on insurance type.
Normally, the following fields are taken from insurance selected for CMS1500 creation:
- "Policy or FECA number" (or "Group Number", if former field is empty) - Box 11
- Insured person's DOB and Gender - Box 11.a
- Insurance Plan Name - Box 11.c
If selected insurance is secondary and it's type is Medicare, then these values are taken from Primary Insurance.
If the relationship to Insured is "Self", then DOB and Gender (Box 11.a) are taken from the Client Details page.
Box 11.b is not filled by My Clients Plus.
Box 12
If "Release Medical Records and Billing Info to Insurance" flag from Bill To & Insurance Info page is "Yes", then "SIGNATURE ON FILE" value is used; Date is the date of form creation.
If the flag is off, then both fields are empty.
Box 13
If "Authorize Payment to Provider" flag from Bill To & Insurance Info page is "Yes", then "SIGNATURE ON FILE" value is used.
If the flag is off, then the field is empty.
Box 14, 15, 16
Is not filled by My Clients Plus.
Box 17
Populated from Referrer section on the Bill To & Insurance Info page of a Client's record.
The name and NPI of the referring provider must be entered in order for box 17 to populate.
Qualifier: "DN" if referrer name has value, otherwise it's empty (both Name and Qualifier depend on Referrer NPI).
The modifier DQ will populate when the toggle for "Use Supervising Provider on Claims" is marked to YES. You can only toggle "Use Supervising Provider on Claims" when the referring provider's full name and NPI is populated.
Box 17.a is not filled by My Clients Plus.
Box 17.b is Referrer NPI.
Box 18, 19, 20
Is not filled by My Clients Plus.
Box 21
Diagnoses’ for services billed.
ICD Version: ICD-9: 9
ICD 10: 0
ICD-9 is used only for services performed before October 1, 2015.
Diagnosis codes are taken from Initial Assessment of cases that contain progress notes related to services billed
Invoice:
Related progress notes:
Box 22
Populated by first selecting "Ask for resubmission details prior to Re-Submit failed claim" in the EDI file settings of the Insurer Details page (Billing > Insurers).
When resubmitting the claim from the Submitted Claims page, enter the required resubmission details:
Resubmission Code
Original Reference Number (you may need to call the payer to get the Original Reference Number)
Resubmission details appear in Loop 2300 of the EDI file and Box 22 of form CMS1500:
Box 23
Prior Authorization Number from Bill To & Insurance Info page.
Box 24
Billed services.
Column Descriptions
- Date of service is taken from Start and End date and time of appointment.
- Place of Service is pulled from the invoice. The dropdown suggests standard values (http://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html), the default value is Office (code 11).
- Is not filled in TN.
- CPT service codes and their modifiers.
- Diagnosis pointer: Letter index(es) of diagnosis in box 21.
- Charges - amount billed for services pulled from invoice.
- Units of service pulled from invoice
- Is not filled in TN.
- ID Qualifier of Additional Insurer ID. Valid additional IDs for 24.I must meet the following conditions:
- The valid qualifier values are:
- 0B State License Number
- 1G Provider UPIN Number
- G2 Provider Commercial Number
- LU Location Number
- ZZ Provider Taxonomy.
- Locations of Additional IDs must be "Any" or match Rendering Provider's location. Rendering provider is specified on invoice, location is specified on User Details page.
- "Related To" field is "Organization & Any Staff" or matches rendering provider's name.
- Qualifier is taken from the first Additional Id of sorted by location(items with specific location have higher priority than non-location-specific items) valid additional ids.
- The valid qualifier values are:
- Record consists of two lines.
- The first line is populated with ID Number of Insurer's Additional ID from column 24.I.
- The second line is populated with Rendering Provider NPI of the "Staff Member" on the invoice.
- If PQRS is used, PQRS measures are also put into box 24 after corresponding service.
- QDC codes are places in column D, diagnosis pointer points to one of diagnoses of parent service.
- Charged sum is $0.01.
Box 25
Depends on Billing Provider specified in invoice.
If "Bill with selected staff NPI?" box is checked, Tax ID of selected Provider is used.
Otherwise Tax ID of Organization is used.
Box 26
Client ID Number on Client Details page.
Box 27
Value of Accept Assignment flag on Bill To & Insurance Info page.
Box 28
Sum of charges for all services.
Box 29
Sum of payments on invoice.
Box 30
Is not filled by My Clients Plus.
Box 31
Name of Rendering Provider associated with invoice.
If no staff is associated with invoice, then "SIGNATURE ON FILE" is printed.
Date: date of form creation.
Box 32
Contains several lines:
Line 1 – Facility Name, i.e. Organization's legal name.Line 2 - Location Address: Number, Street, Suite.
Line 3 - Location Address: City, State, Zip.
If invoice's service item has associated appointment, Location is pulled from the appointment. Otherwise it's pulled from the Client Details page.
Box 32.a is facility NPI of Location. If it's not specified, then Facility NPI of organization is used.
Box 32.b. is not filled by My Clients Plus.
Box 33
The box content depends on Billing Provider and Provider's location that are specified on invoice page:
1) Billing provider address values and Phone Number are taken from "Send Payments To (if different from Location)" section, and if it's empty (i.e. all fields of the section are empty), then values from "Location Address" section are used.
2) Billing Provider Name: if "Bill with selected staff NPI?" box is checked and Provider is selected, then this Provider's name is used.
Otherwise Organization's legal name is used.
Box 33.a.
Contains Billing Provider's NPI. Otherwise organization's NPI is used.
Box 33.b.
Field is constructed from qualifier and ID Number of first valid Additional ID of current Insurer.
The allowed qualifiers for box 33.b are:
- 0B State License Number
- G2 Provider Commercial Number (currently only prints on the physical CMS-1500. It is not sent in the electronic file)
- ZZ Provider Taxonomy
If provider is a used:
The first additional id is taken that matches following conditions:
- its qualifier belongs to allowed qualifiers.
- its location is "Any" or matches Provider's location specified in invoice
- "Related To" field is "Organization & Any Staff" or Billing Provider's name.
If Provider is Organization:
The first additional id is taken that matches following conditions:
- Its qualifier belongs to allowed qualifiers.
- Its location is "Any" or matches Provider's location specified in invoice
- "Related To" field is "Organization & Any Staff" or "Organization".