Health insurance claim form CMS 1500 Flashcards

11273054136	1.	Insurance type	0
11273054137	1a.	Insured's ID Number	1
11273054138	2.	Patient's name (last, first, middle inital)	2
11273054139	3.	Patient's DOB	3
11273054140	4.	Insured's name (last, first, middle inital)	4
11273054141	5.	Patient's address, city, state, zip, telephone number	5
11273054142	6.	Patient's relationship to insured	6
11273054143	7.	Insured's address, city, state, zip, telephone number	7
11273054144	8.	Reserved for NUCC use	8
11273054145	9.	Other insured's name (last, first, middle initial)	9
11273054146	9a.	Other insured's policy or group number	10
11273054147	9b.	Reserved for NUCC use	11
11273054148	9c.	Reserved for NUCC use	12
11273054149	10	Is patient's condition related to:	13
11273054150	10a.	Employment	14
11273054151	10b.	Auto accident	15
11273054152	10c.	Other accident	16
11273054153	11.	Insured's policy group or feca number	17
11273054154	11a.	Insured's Date of Birth, Sex	18
11273054155	11b.	Other Claim ID (Designated by NUCC)	19
11273054156	11c.	Insurance plan name or program name	20
11273054157	11d.	Is there another health benefit plan?	21
11273054158	12.	Patients or authorized person's SIGNATURE Authorize the release of any medical or other information necessary to process this claim	22
11273054159	13.	Insured's or authorized persons signature, i authorize payment of medical benefits to the undersigned physician or supplier for services described below.	23
11275552318	14.	Date of current: illness, injury, or pregnancy (LMP)	24
11275552319	15.	Other date	25
11275552320	16.	Dates patient unable to work in current occupation	26
11275552321	17.	Name of referring provider other other source	27
11275552322	17a	Blank	28
11275552323	17b.	Referring provider's NPI	29
11275552324	18.	Hospitalization dates related to current services	30
11275552325	19.	Additional claim information (designated by NUCCI)	31
11275552326	20.	Outside lab? $ Charges	32
11275552327	21.	Diagnosis or nature of illness or injury	33
11275552328	22.	Resubmission code, original ref. No.	34
11275552329	23.	Prior authorization	35
11275552330	24a.	Dates of service	36
11275552331	24b.	place of service	37
11275552332	24c.	EMG	38
11275552333	24d.	Procedures, services, or supplies CPT/HCPCS, Modifers	39
11275552334	24e.	Diagnosis Pointer	40
11275552335	24f.	charges	41
11275552336	24g.	Days or Units	42
11275552337	24h.	EPSDT family plan	43
11275552338	24i.	ID Qual	44
11275552339	24j.	Rendering Provider ID #	45
11275552340	25.	Federal tax ID number SSN EIN	46
11275552341	26.	Patient's account no.	47
11275552342	27.	Accept assignment	48
11275552343	28.	Total charge	49
11275552344	29.	Amount paid	50
11275552345	30.	Rsvd for NUCCI Use	51
11275552346	31.	Signature or physician or supplier including degrees or credentials	52
11275552347	32.	Service facility location information	53
11275552348	32a.	NPI number for box 32	54
11275552349	32b.	Leave blank	55
11275552350	33.	Billing provider info & ph #	56
11275552351	33a.	NPI# for box 33	57