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CMS 1500 - Health Insurance Claim Form

Jane is now able to generate a CMS 1500 form into an editable PDF!

Here’s the information you need to ensure all the data is populated onto the form.

Clinic Settings

​1. Each of your US insurers should have an address and the type of Insurance Program selected.

​Under Settings > Insurers >, click View to check that an insurance program has been selected:

​ ​2. Set your NPI and place of service code for the clinic. ​Head to Settings > Clinic Info & Locations, scroll down and click into your location.

At the bottom you’ll see the area to add this information:

Staff Settings

​3. In the “ID Numbers” section of a staff profile add both NPI (National Provider Identifier) and either SSN, TIN or EIN federal tax ID numbers.

Note: Jane only places one Federal Tax I.D on the form, so she will prioritize SSN then, EIN and finally the TIN.

​Jane will use these to populate on to the CMS1500: ​

Claim Settings

​When you create a claim for a patient, you can enter all the relevant details for that patient and their claim:

The information on the above area (see screenshot about) of the claim will populate on a CMS-1500 form as follows:

  • Claim Identification Number: Box 1a
  • Policy Number: Box 11
  • Insurance Plan Name: Box 11c
  • Prior Authorization Number: Box 23

The information on the above area (see screenshot about) of the claim will populate on a CMS-1500 form as follows:

  • Injury Date: Box 14
  • Signature on File: Box 13
  • Accept Assignment: Box 27

The information on the above area (see screenshot about) of the claim will populate on a CMS-1500 form as follows:

  • Insured’s Info: Box 6, 7, & 9
  • Is the patient’s condition related to: Box 10
  • Date of Current Illness Injury, or Pregnancy: Box 14
  • Enter Another date related to the patient’s condition or treatment: Box 15
  • Dates Patient Unable to Work in Current Occupation: Box 16
  • Hospitalization Dates Related to Current Services: Box 18

The information on the above area (see screenshot about) of the claim will populate on a CMS-1500 form as follows:

  • Name and ID numbers of who referred or ordered the service(s) or supply(ies): Box 17

Generating the CMS1500

​Once you have added the claim to the appointment and Arrived the appointment, click the downward arrow next to the “Pay” button and select Generate CMS1500:

​Jane will tell you if there are any missing fields and then generate the form.

​This form can be edited further if required. Save or Print from there;

​Note: SOF stands for Signature on File.

​This is an accepted term but feel free to remove this is you are printing and signing.

​These will print best on blank paper and you’ll need to print in colour if you require the red form for Medicare purposes.

Want to export multiple CMS-1500 forms in one go? If so, check out the following guide: Generating a Batch: Superbills & CMS-1500s

Happy Billing!