Where the information comes from for the 1500 Form

(Numbers equate to 1500 Form Box Numbers)

     1.      Setup>Insurers (top section: Type)

  MEDICARE: Setup>Insurers (Select Medicare)

  MEDICAID: Setup>Insurers (Select Medicaid)

  TRICARE: Setup>Insurers (Select ChampUS)

  CHAMPVA: Setup>Insurers (Select Champ VA)

  GROUP HEALTH PLAN: Setup>Insurers (Select Group Health Plan)

  FECA BLK LUNG: Setup>Insurers (Select FECA)

  OTHER: Setup>Insurers (Select Other)


1a.   Medicare: Patients (select patient) Payees>Member #

         Mecicaid: Patients (select patient) Payees>Member #

         Tricare (ChampUS): Patients (select patient) Payees>Member #

         ChampVA: Patients (select patient) Payees>Member #

         Group Health Plan: Patients (select patient) Payees>Member #

         FECA: Patients (select patient) Payees>Member #

         Other: Patients (select patient) Payees>Member #


2.      Patients Name: Patients (select patient): Profile Info (Main Page: Top)


3.      Patients Birth Date / Sex: Patients (select patient) Patients Profile (Main Page: Top)


4.      Insured’s Name: Patients (select patient) Payees (Insured)


5.      Patient’s Address: : Patients (select patient): Profile Info (Main Page: Top)


6.      Patient Relationship to Insured: Patients (select patient): Billing Section (Pat. Rel)


7.      Insured’s Address: Patients: Patients (select patient) Payees (Insured)


8.      Reserved for NUCC Use:


9.      Other Insured’s Name (When Billing Secondary): Patients>Payees (Primary Insurance: Insured – If marked other)


9a.    Other Insured’s Policy or Group Number: (When Billing Secondary): Patients>Payees (Primary Insurance: Group #)


11.    Insured’s Policy Group or FECA Number: Patients (select patient) Payees (select payee) Group # field


11a.  Insured’s Date of Birth: Patients (select patient) Payees (select payee) D.O.B. field


11c.  Insurance Plan Name or Program Name: Patients (select patient) Payees (select payee) Plan Name field


12.    Patient’s or Authorized Person’s Signature: Patients (select Patient) Billing section – Signature on File (Box 12)


13.    Insured’s or Authorized Persons Signature: Patients (select Patient) Billing section – Signature on File (Box 13)


14.    Date of Current Illness, Injury or Pregnancy: Is Populated from the Onset Date or Same or Similar date in the Evaluation. If both dates are present, the Same or Similar date will be used.


17.    Name of Referring Provider: Setup>Physicians (select Physician) First Name and Last Name fields


17a.  Setup>Physicians (select Physician) Taxonomy # field


17b.  NPI: Setup>Physicians (select Physician) NPI# field


19.    Additional Claim Information: Billing (Invoices) select invoice – 1500 Form Fields: 19. Reserved Box


21.    Diagnosis: Billing (Invoices) – Treatments on Invoice: Diag1, Diag2, Diag3, Diag4 fields

         ICD ind.: If ICD 9’s being billed – 9; if ICD 10’s being billed - 0


22.   Billing>Invoices, select the patient and open the invoice by clicking on it representing the DOS in question


23.    Prior Authorization Number: Patients (select patient) Payee Section (select Payee) Authorizations (near bottom of page)


24a.  Dates of Service: Billing (Invoices) select invoice – Treatments on Invoice: Treat. Date


24b.  Place of Service: Visits (select visit) – Start (Date Field)


24d.  CPT/HCPCS or Modifiers: Billing (Invoices) select invoice  – Treatments on Invoice: CPT and Modifier fields


24e.  Diagnosis Pointer:


24f.   $ Charges: Billing (Invoices) select invoice – Treatments on Invoice - Charge Column


24g.  Days or Units: Billing (Invoices) select invoice – Treatments on Invoice - Units Column


24i.   ID Qualifier: zz- If zz number is on Therapist Profile or Facility Information.  If no zz numbers, code would then depend on Rendering provider ID Type added to the Insurer on the Users Profile (Rendering Provider ID     Numbers)


24j.   Rendering Provider ID Number: If zz number is on Therapist Profile or Facility Information.  If no zz numbers, code would then depend on rendering provider ID number added to the Insurer on the Users Profile (Rendering Provider ID Numbers)


NPI:  Setup>Users/Therapists (select user) Therapist Profile: NPI # Field


25.    Federal Tax I.D. Number: Setup>Facilities (select facility) - Billing Provider Info: EIN


26.    Patients Account Number: Patients (select Patient) Number (Main Page: Top)


27.    Accept Assignment: Setup>Insurers (select Insurer): Top Section (Accept Assignment Check Box)


28.    Total Charge: Billing>Invoice (Select Invoice) – Treatments on Invoice - Charge Column (Sum of Charges)


29.    Amount Paid: Fills in automatically with amount paid by Primary Ins when billing to Secondary


31.    Signature of Physician or Supplies: Setup>Users/Therapists (select User): User Profile Section – Signature Field (type in first and last name of therapist) or Setup>Insurers and enable custom fields and enter information in to Box 31 which will override the Therapist Signature for the particular Insurer being modified.


32.    Service Facility Location Information: If on noted on a Visit, Location is set to Office, then: Setup>Facilities (select Facility) – Service Facility Location Information


If noted on a Visit, Location is set to anything other than Office, then: Patients: Service Locations 


32a.  Setup>Facilities (select Facility): Service Facility Location info (NPI Field)


32b.  Setup>Insurers (select Insurer): Provider # and Type, If none; Setup>Facilities (select Facility): Service Facility Location Info - Provider Info: Taxonomy Number


33.    Billing Provider Info: Setup>Facilities (select Facility): Billing Provider Info


33a.  Setup>Facilities (select Facility): Billing Provider Info (NPI Field)


33b.  Setup>Insurers (select Insurer): Provider # and Type, If none; Setup>Facilities (select Facility): Billing Provider Info: Taxonomy Number

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