CMS1500

Intellect Screen(s) & Field(s)

Box 1

Utility --► Insurance --► Insurance  <Insurance Type>

Box 1a

Registration --► Worker --► Worker Insurance <BOX 1A/CLAIM#>

Box 2

Registration --► Worker --► Worker <Last Name>, <First Name>, <Middle Initial>

Box 3

BIRTHDATE: Registration --► Worker --► Worker  <DOB>

SEX: Registration --► Worker --► Worker  <Gender>

Box 4

Registration --► Worker --► Worker Insurance <Employer>

Box 5

PATIENT’S ADDRESS:  Registration --► Worker --► Worker  <Address>

CITY: Registration --► Worker --► Worker  <City>

STATE: Registration --► Worker --► Worker  <State>

ZIP CODE: Registration --► Worker --► Worker  <Zip Code>

TELEPHONE: Registration --► Worker --► Worker   <Home Phone>

Box 6

Prints ‘X’ in Other box if registered under Registration --► Worker --► Worker.

Box 7

INSURED’S ADDRESS: Registration --► Worker --► Worker Insurance  (Employer) <Address>

CITY: Registration --► Worker --► Worker Insurance  (Employer) <City>

STATE: Registration --► Worker --► Worker Insurance  (Employer) <State>

ZIP CODE: Registration --► Worker --► Worker Insurance  (Employer) <Zip Code>

TELEPHONE: (blank)

Box 8

(blank)

Box 9

(blank)

Box 9a

(blank)

Box 9b

(blank)

Box 9c

(blank)

Box 9d

(blank)

Box 10

a. EMPLOYMENT: Charges --► Encounter --► Generic <Employment (Y/N)> OR

Registration --► Worker --► Worker Insurance <Employment>

b. AUTO ACCIDENT: Charges --► Encounter --► Generic (Ambulance, or DME) <Related: Accident (A/O/N)> OR Registration --► Worker --► Worker Insurance <Related Accident (A/O/N)>

Place (state): Registration --► Worker --► Worker  <State>

c. OTHER ACCIDENT: Charges --► Encounter --► Generic (Ambulance, or DME) <Related: Accident (A/O/N)> OR Registration --► Worker --► Worker Insurance <Related Accident (A/O/N)>

Box 10d

Billing --► Worker --► Statement <Type of Report> OR

Billing --► Worker --► HCFA <Type of Report>

Box 11

Registration --► Worker --► Worker Insurance  <Group No.>

Box 11a

INSURED’S DATE OF BIRTH: (blank)

SEX: (blank)

Box 11b

Registration --► Worker --► Worker Insurance <Claim No. 1>

Box 11c

(blank)

Box 11d

(blank)

Box 12

SIGNED: Utility --► Insurance --► Insurance <Message Box 12 & 13>

DATE: Utility --► Set Up --► Clinic <Current Entry Date>

Box 13

Utility --► Insurance --► Insurance <Message Box 12 & 13>

Box 14

Registration --► Worker --► Worker Insurance <DOI> OR

Charges --► Encounter --► Generic (Ambulance, DME Oxygen or Vision) <Injury Date>

Box 15

Charges --► Encounter --► Generic <Report Start>, <Report End>, <Last Seen>, <First Consulted> or <X-Ray Date>  OR

Charges --► Encounter --► Chiropractic <Last Seen>, <Acute Manifestation>, <Initial Treatment>or <X-Ray Date>  OR

Charges --► Encounter --► Physical Therapy <Last Seen> or <X-Ray Date> OR

Charges --► Encounter --► Vision <Prescription Date>

Box 16

FROM: Charges --► Encounter --► Generic <Unable to Work From>

TO: Charges --► Encounter --► Generic <Unable to Work To>

Box 17

DN: Charges --► Charge <Ref Prv> OR Registration --► Worker --► Worker <Referral> OR Charges --► Charge <Billing Prv>

DK: Charges --► Encounter --► Generic (Ambulance, DME, or DME Oxygen) <Ordering Provider>

DQ: Charges --► Encounter --► Generic (or Physical Therapy) <Supervising Provider>

Box 17a

QUALIFIER: Utility --► Insurance --► Insurance <Referring Type>

Utility --► Referring <UPIN Number> or <Provider No.> or <State License> or <NPI> or <Commercial> or <Blue Shield> or <Tax ID>

Box 17b

Utility --► Referring <NPI> OR Utility --► Provider --► Provider <NPI>

Box 18

FROM: Charges --► Encounter --► Generic (Ambulance, Epogen, or OBGYN) <Hospitalization From>

TO: Charges --► Encounter --► Generic (Ambulance, Epogen, or OBGYN) <Hospitalization To>

Box 19

Charges --► Encounter --► Generic (or OBGYN) <Box 19 Claim Notes> and <HCFA Box 19 Date> OR

Charges --► Encounter --► Generic <Project Identifier>

Box 20

OUTSIDE LAB: Charges --► Encounter --► Generic <Referred Lab>

$CHARGES$: Utility --► Procedure --► Procedure <Cost>

Box 21

ICD ind: Utility --► Diagnosis --► Diagnosis <ICD9/ICD10>

A through L: Charges --► Charge <Diagnosis Code>

Box 22

RESUBMISSION CODE: Charges --► Encounter --► Generic (Ambulance, Chiropractic, Epogen, OBGYN, Physical Therapy, or Vision) <Claim Frequency Code>

ORIGINAL REF. NO: Charges --► Encounter --► Generic (Ambulance, Chiropractic, Epogen, OBGYN, Physical Therapy, or Vision) <Internal Control>

Box 23

Charges --► Encounter --► Generic (Ambulance, Chiropractic, Epogen, OBGYN, Physical Therapy, or Vision) <Authorization No>

OR

Utility --► Provider --► Provider Facility <CLIA> or Utility --► Provider --► Provider <CLIA> or Utility --► Facility <CLIA>

Box 24A

FROM: Charges --► Charge <From Date>

TO: Charges --► Charge <To>

Box 24B

Utility  --► Facility <Place of Service>

Box 24C

Charges --► Encounter --► Generic <Emergency (Y/N)> OR <Delay Reason Code>

Box 24D

CPT/HCPCS: Utility --► Procedure --► Procedure <Code R>, <Code C>, <Code E>, <Code O> or <Revenue Code> for Charges --► Charge <Panel>

MODIFIER: Charges --► Charges <Mod>

Box 24E

Charges --► Charge <RDX>

Box 24F

Charges --► Charge <Charge>

Box 24G

Charges --► Charge <Qty>

Box 24H

(blank)

Box 24I

Utility --► Insurance --► Insurance <Box 24J Type>

Box 24J

(top line): For billing provider, Utility --► Provider --► Provider <Taxonomy> OR

(in order of hierarchy) Utility --► Provider --► Provider Facility <HCFA Box 24 J> OR Utility --► Provider --► Provider Provider <HCFA Box24 J> OR Utility --► Provider --► Provider <HCFA Box 24 J1>, <HCFA Box 24 J2> or <HCFA Box 24 J3>

NPI: Utility > Provider > Provider <NPI> for billing provider

Box 25

For Billing Method by Clinic: Utility --► Set Up --► Clinic <IRS Number>

For Billing Method by Doctor: (in order of hierarchy) Utility --► Provider --► Provider Facility <Tax ID> OR Utility --► Provider --► Provider Provider <Tax ID> OR Utility --► Provider --► Provider <I.R.S.>

Box 26

Registration --► Worker --► Worker <Patient Account No>

Box 27

Charges --► Charge <ASI>

Box 28

Sum of all charges in Box 24F lines 1 through 6

Box 29

Utility --► Insurance --► Insurance <Include Payment>

Box 30

(blank)

Box 31

SIGNED: Charges --► Charge <Billing Prv>

DATE: Utility --► Set Up --► Clinic <Current Entry Date>

Box 32

Charges --► Charge <Facility> OR Charges --► Encounter --► Generic <Referred Lab>

Box 32a

Utility --► Facility <NPI>

Box 32b

Utility --► Facility <Provider 1> , <Provider 2> or <Provider 3> OR

Utility --► Procedure --► Procedure <Mammography>

Box 33

For Billing Method by Clinic: Utility --► Set Up --► Clinic <Clinic Name>, <Address>, <City>, <State>, <Zip Code>, <Phone>

For Billing Method by Doctor: Utility --► Provider --► Provider <Organization Name> or <First Name> <Middle Initial> <Last Name> <Title>, <Address>, <City>, <State>, <Zip Code>, <Phone Number>

Box 33a

For Billing Method by Clinic: Utility --► Insurance --► Insurance <Group NPI>

For Billing Method by Doctor: (in order of hierarchy) Utility --► Provider --► Provider Facility <Group NPI> OR Utility --► Provider --► Provider Provider <Group NPI> OR Utility --► Provider --► Provider <Group NPI>

Box 33b

Utility --► Insurance --► Insurance <Box 33 Type> AND

For Billing Method by Clinic: Utility --► Insurance --► Insurance <1500 Form Box 33 Group>

For Billing Method by Doctor: (in order of hierarchy) Utility --► Provider --► Provider Facility <HCFA Box33> OR Utility --► Provider --► Provider Provider <HCFA Box33>  OR Utility --► Provider --► Provider <HCFA Box 33 1>, <HCFA Box 33 2> or <HCFA Box 33 3>