CMS 1500 Form Boxes & Corresponding OfficeMate Fields (OfficeMate v8.0)

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Q12506 - INFO: CMS 1500 Form Boxes & Corresponding OfficeMate Fields (OfficeMate v8.0)

The CMS 1500 imports information entered into OfficeMate. You can edit some information directly on the CMS 1500 form, but most information must be edited in OfficeMate as described below.

Note: OfficeMate automatically populates the appropriate form fields based on the type of insurance. For example, if the patient is insured by Medicare, OfficeMate completes only the fields required by Medicare.

CMS Box	OfficeMate field/window
Box 1	Insurance Type drop-down menu on Insurance tab on the Business Names window
Box 1A	Insurance tab on the Patient Demographic window
Box 2 & Box 3	Name and Date of Birth fields on the Patient Demographic window
Box 4	Insured Party field in the Insurance tab on the Patient Demographic window Medicare: Blank if the Insured Party and the Patient are the same. Other Insurance: "SAME" if the Insured Party and the Patient are the same.
Box 5	Address fields on the Patient Demographic window
Box 6	Relationship to Insured drop-down menu on the Insurance tab on the Patient Demographic window
Box 7	Insured Party field in the Insurance tab on the Patient Demographic window (if Other or Guarantor is selected as the insured party) Medicare: Blank if the Insured Party and the Patient are the same. Other Insurance: "SAME" if the Insured Party and the Patient are the same.
Box 8	Marital Status and Emp. Status drop-down menus on the Patient Demographic window
Box 9, 9A, & Box 9C	Insured Party field on the Insurance tab on the Patient Demographic window (if Other or Guarantor is selected as the insured party). This field can be manually edited on the CMS 1500 form or can be automatically populated by selecting the "Populate current insurance in box 9 on the CMS" check box on the Insurance tab on the Patient Demographic window.
Box 9D	Insurance Name field in the Insurance tab on the Patient Demographic window
Box 10	The default is NO, but you can change it.
Box 11	Policy Group No drop-down menu on the Insurance tab on the Patient Demographic window
Box 11A–C	Insured Party field in the Insurance tab on the Patient Demographic window (if Other or Guarantor is selected as the insured party) Medicare: Blank if the Insured Party and the Patient are the same. Other Insurance: Box A populates if the Insured Party and the Patient are different; if they are the same, box B remains blank if no employer is recorded but is populated if an employer is recorded, and box C remains blank.
Box 11D	The default is NO, but it is automatically changed to YES if there is another insurance carrier selected in Box 9D.
Box 12	Signature Source drop-down menu on the Insurance tab on the Patient Demographic window
Box 13	Signature Source drop-down menu on the Insurance tab on the Patient Demographic window. If the guarantor is not a patient, NO SIGNATURE ON FILE will be displayed in box 13. You can edit this box if necessary.
Box 14, Box 15, & Box 16	You can edit these boxes.
Box 17	Name of referring professional (if one is selected) in the Referred Name field on the Patient Demographic window. You can set up a preference to automatically populate this box from the CMS tab on the System Preferences window or you can edit the referring doctor’s name directly on the CMS 1500 form.
Box 17A	Qualifier and Other ID fields on the Referring Dr. tab on the Business Names window
Box 17B	NPI Number field on the Referring Dr. tab on the Business Names window
Box 18	You can edit this box.
Box 19	You can edit this box. If you are submitting an ANSI file to an insurance company, the text that you type in the Item Narrative text box on the Fee Slip Line Additional Data window appears in electronic claim files and in place of box 19 on the printed CMS 1500 form.
Box 20	You can edit this box.
Box 21	Diagnosis code in the ICD-9 field on the Fee Slip window
Box 22 & Box 23	You can edit these boxes.
	CMS 1500 form boxes 24A–24J are divided horizontally to accommodate the submission of both the NPI number and another/proprietary identifier during the NPI transition and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information; it is not intended to allow for the billing of 12 lines of service.
Box 24A	Posting date on the Fee Slip window or service dates on the Fee Slip Item Additional Data window
Box 24B	Place of Service drop-down menu in the CMS - 1500 Additional Information box on the Products window
Box 24C	EMG field on the Products window
Box 24D	CPT code on the Fee Slip window. Modifiers for services are extracted from the Products window or the Fee Slip Item Additional Data window and modifiers for all other product types are extracted from the Fee Slip Item Additional Data window.
Box 24E	Diagnosis pointer (1 2 3 4 or any combination of these numbers) referencing the line number(s) from box 21. Reference the primary diagnosis code first, then the secondary diagnosis code, and so on.
Box 24F	Displays charges from the Products window if the Yes radio button is selected next to the "Use ‘Product Fee’ on CMS" option on the CMS tab in the System Preferences window; otherwise, displays charges from the Fee box on the Fee Slip window.
Box 24G	Quantity column on the Fee Slip window. If you are required to report NDC units, click on the arrow on the right side of box 24J and type the appropriate qualifier in the Box 24 Supplemental Information text box (F2=International Unit; ML= Milliliter; GR=Gram; UN=Unit).
Box 24H	EPSDT field on the Products window. If there is a requirement for you to report a reason code for EPDST, click on the arrow on the right side of box 24J and select the appropriate reason code from the EPSDT Codes drop-down menu (AV=Available; S2=Under Treatment; ST=New Service Requested; NU=Not Used; Y=Yes; N=No).
Box 24I	Type drop-down menu on the Insurance tab on the Business Names window, if the type is different than what is already recorded in box 33B. Based on your selection from the Type drop-down menu on the Insurance tab on the Business Names window, the following qualifiers will be populated in the shaded section of the box: Blue Cross–1A, Blue Shield–1B, Medicare–1C, Medicaid–1D, Champus–1H, Commercial–G2, Other–1G. If required or needed, enter or modify information in box 24I by clicking on the arrow on the right side of box 24J and selecting a qualifier from the drop-down menu.
Box 24J	The submitter ID field or, if that is not available, Pin #, on the Insurance Information window (Provider/Staff tab on the Business Names window) is populated in the shaded section and the NPI Number field on the Provider/Staff tab on the Business Names window is populated in the unshaded section of the box, if this information is different than what is already recorded in box 33A. In order to preview this box populated with information in OfficeMate or record supplemental information, you must click on the arrow on the right side of the box. The information will automatically display in the box when you create a print image file or print the CMS 1500 form. Type supplemental information in the Box 24 Supplemental Information text box if you are required to report information not already recorded. Follow payer instructions for using qualifiers; when reporting a service that does not have a qualifier, type two blank spaces before typing the information. Do not enter a space between the qualifier and the number/code/information. Do not enter hyphens or spaces within the number/code. To record more than one supplemental item, type the first item, three blank spaces, and then the next item. If required or needed, enter or modify information in the shaded portion of box 24J by typing the rendering provider ID in the Box 24J Rendering Provider ID text box. Any supplemental information that you record is populated in the shaded sections of boxes 24A–24G.
Box 25	Tax ID field in the Provider/Staff tab on the Business Names window
Box 26	Patient # on the Patient Demographic window
Box 27	Accept Assign? and Don’t Accept Assign? fields on the Insurance Information window (Provider/Staff tab on the Business Names window)
Box 28	Total Charges field on the Fee Slip window
Box 29	You can edit this box. Any amounts paid by the patient do not impact this box.
Box 30	Total Charges field on the Fee Slip window
Box 31	Business Names window. This box is blank if the assignment indicator is not checked on the Insurance Information window (Provider/Staff tab on the Business Names window).
Box 32	Place of Service tab on the Business Names window or Business tab on the Business Names window (if the Print Business Address in Box 32 check box is selected on the Insurance tab on the Business Names window)
Box 32A	If the Print Business Address in Box 32 check box is selected on the Insurance tab on the Business Names window, then the NPI Number field on the Business tab on the Business Names window is populated. If the Print Business Address in Box 32 is not selected on the Insurance tab on the Business Names window, then you must select the NPI number that is recorded in the NPI Number field on the Place of Service tab on the Business Names window from the Box 32A drop-down menu.
Box 32B	If the Print Business Address in Box 32 check box is selected on the Insurance tab on the Business Names window, then the Qualifier and Facility ID fields on the Business tab on the Business Names window are populated. If the Print Business Address in Box 32 is not selected on the Insurance tab on the Business Names window, then you must select the qualifier and facility ID that are recorded in the Qualifier and Facility ID fields on the Place of Service tab on the Business Names window from the box 32B drop-down menu.
Box 33	Business tab on the Business Names window
Box 33A	NPI Number field on the Business tab on the Business Names window
Box 33B	Group # (or Pin # if there is no Group #) on the Insurance Information window (Provider/Staff tab on the Business Names window). If the insurance type is not Blue Cross (1A), Blue Shield (1B), Medicare (1C), Medicaid (1D), Champus (1H), or Commercial (G2), the UPIN # on the Provider/Staff tab on the Business Names window is populated instead of the Group #.