Step 9 - CMS-1500 Specs

Training Video

This chapter is extremely useful when you find an error on your scoring report that you want to locate in ClaimGear and correct.


The scoring report provides a box number and lists the data entry error.  Locate this box number on the Specs (see page 77).  The Specs provide instructions on how to navigate through ClaimGear to the exact field an error has occurred.  Make the corrections and click the Save button.
CMS-1500 Claim Form
Below is an example of the CMS-1500 claim form.  The box numbers referred to on the scoring report and on the Specs are also on the box numbers on the CMS-1500 claim form.
 
 
 
 
 CMS-1500 Specs
 

CLAIMGEAR  CMS-1500 SPECS

BOX            DESCRIPTION OF FIELD ON FORM AND IN CLAIMGEAR

                   LOCATION OF FIELD IN CLAIMGEAR




1

 1

Payer/Carrier Type


 

Payer -F6 tab, Find or Add, Payer Type

 

a

Insured's ID Number

 

 

*Patient -F2 tab, Search or Add, 2 Insured tab, Payers tab, Set Payer 1, enter Member Id#




2

 

Patient's last name, first name, and middle initial

 

 

Patient -F2 tab, 1 Patient tab, enter Last Name, First, MI




3

 

Patient's Date of Birth

 

 

Patient -F2 tab, 1 Patient tab, enter Birth date




4

 

Enter the Insured's last name, first name, and middle initial

 

 

Patient -F2 tab, 2 Insured tab, enter Last Name, First, MI




5

 

Patient's Address

 

 

*Patient -F2 tab, 1 Patient tab, enter Address




6

 

Patient Relationship to Insured

 

 

*Patient -F2 tab,  2 Insured tab, enter Patient Relationship to the Insured?




7

 

Insured's Address

 

 

*Patient -F2 tab, 2 Insured tab, enter Address




8

 

Patient Status: Single, Married, Other, Employed, Full-Time Student, Part-Time Student

 

 

Patient -F2 tab, 1 Patient tab, Defaults tab, enter Marital Status or Student Status or Employed Status




9

 

Other Insured's Name (Last, First, MI).  2 ways:

 

 

*1) Patient -F2 tab, 2 Insured tab, enter Last Name, First, MI

 

 

*2) Patient -F2 tab, 3 Other Insured tab, enter Last Name, First, MI

 

9a

Other Insured's Policy AND Group number

 

 

*1) Patient -F2 tab, 2 Insured tab, Payers tab, Payer 2, enter Group Number AND Member ID#

 

 

*2) Patient -F2 tab, 3 Other Insured tab, Payer 3, enter Group Number AND Member ID#

 

9b

Other Insured's Date of Birth

 

 

*1) Patient -F2 tab, 2 Insured tab, enter Birth date

 

 

*2) Patient -F2 tab, 3 Other Insured tab, enter Birth date

 

9c

Other Insured's Employer's Name

 

 

*1) Patient -F2 tab, 2 Insured tab, Employer tab, enter Employer Name

 

 

*2) Patient -F2 tab, 3 Other Insured tab, enter Employer Name

 

9d

Insurance Plan Name

 

 

*1) Patient -F2 tab, 2 Insured tab, Payers tab, Payer 2, enter Payer 2 by 'New Payer' or 'Find Payer'

 

 

*2) Patient -F2 tab, 3 Other Insured tab, Payer 3, enter Payer 3 by 'New Payer' or 'Find Payer'




10

 

Patient's Condition; Type of Accident

 

 

1) Claim -F1 tab, 3 Additional Info tab, enter Yes for specific accident type (10b requires state abbreviation)




11

 

Insured's Policy Group Number

 

 

*Patient -F2 tab, 2 Insured tab, Payers tab, Payer 1, enter Group Number

 

11a

Insured's Date of Birth

 

 

*Patient -F2 tab, 2 Insured tab, enter Birth date

 

11b

Enter the Employer's name

 

 

*Patient -F2 tab, 2 Insured tab, Employer tab, enter Employer Name

 

11c

Insurance Plan Name

 

 

*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 1 by 'New Payer' or 'Find Payer' button

 

11d

Is there another health benefit plan?

 

 

System defaults this information.  If wrong, see Box 9 and complete correctly.




12

 

Patient's or Auth Signature

 

 

*Patient -F2 tab, 2 Insured tab, enter 'Signed signature authorization form for both Block 12 and 13 are on file'




13

 

Insured's or Auth Signature

 

 

*Patient -F2 tab, 2 Insured tab, enter 'Signed signature authorization form for both Block 12 and 13 are on file'




14

 

Date of Current Illness/Injury/Pregnancy

 

 

1) Claim -F1 tab, 3 Additional Info tab, enter Date of Onset of Illness or Accident or LMP




15

 

Date of Same or Similar Illness

 

 

Claim -F1 tab, 3 Additional Info tab, enter Date of Similar Illness




16

 

Dates Patient Unable to Work in Current Occupation

 

 

Claim -F1 tab, 3 Additional Info tab, enter Unable to Work From Date and To Date


 

17

 

Name of Referring Physician

 

b

Referring Physician NPI

 

 

1) Claim -F1 tab, 1 Claim tab, enter Select Referring/PCP Provider




18

 

Hospitalization Dates Related to Current Services

 

 

Claim -F1 tab, 3 Additional Info tab, enter Hospitalized From Date and To Date




19

 

Reserved For Local Use

 

 

Not applicable




20

 

Outside Lab and Charges

 

 

Claim -F1 tab, 3 Additional Info tab, enter Lab Charges




21

 

Diagnosis

 

 

Claim -F1 tab, 2 Charges tab, enter ICD#




22

 

Medicaid Resubmission Code

 

 

Claim -F1 tab, 3 Additional Info tab, enter Resubmit Reason Code




23

 

Prior Authorization Number

 

 

Claim -F1 tab, 1 Claim tab, enter Authorization # and press 'Copy Authorization to Claim' button




24

 

Charges

 

a-g

Claim -F1 tab, 2 Charges tab, enter Information

 

24a

Dates of Services - From and To Date

 

24b

Place of Service (POS)

 

24d

Procedure code (CPT)

 

24f

Total Charges

 

24g

Units

24

 

Rendering ID Qualifier

 

i

Automatically populate based on payer information

24

 

Non-NPI number

 

j

Payer- F6 tab, Select Payer, Provider ID Numbers tab, enter Individual number

24

 

NPI Number

 

j

Claim F -1 tab, 1 Claim tab, and Select Rendering Provider and Select Billing Provider

24

 

Payment Information - InsPay  InsAdj  InsAllow

 

x

Payment -F3 tab, 3 EOB Posting tab, Find, Search, Select Patient,

 

 

correct insurance payment, adjustment, or allowed




25

 

Federal Tax ID Number

 

 

Claim F -1 tab, 1 Claim tab, and Select Rendering Provider and Select Billing Provider




26

 

Patient's Account No.

 

 

Automatically generated by ClaimGear




27

 

Accept Assignment?

 

 

*Patient -F2 tab, 2 Insured tab, enter 'Yes, The provider accepts the assignment of benefits'




28

 

Total Charge

 

 

Claim -F1 tab, 2 Charges tab, enter Total Charges (= Unit Price X Units)




29

 

Amount Paid

 

 

Payment -F3, enter 1 Line Item Posting (co-pay) OR 3 EOB Posting (Insurance payment) tab




30

 

Balance Due

 

 

Claim -F1 tab, 2 Charges tab, enter Information [= Adjustments + Money Due (by Patient or Insurance)]

 

31

 

Signature Of Physician or Supplier

 

 

Claim -F1 tab, 1 Claim tab, and Select Rendering Provider and Select Billing Provider




32

 

Name and Address of Facility

 

 

Claim -F1 tab, 1 Claim tab, enter Select Facility

 

a

Facility NPI

 

 

Claim -F1 tab, 1 Claim tab, enter Select Facility




33

 

Physicians or Suppliers Billing Information

 

 

Claim -F1 tab, 1 Claim tab, enter Billing Provider

 

a

Billing NPI

 

 

Claim -F1 tab, 1 Claim tab, enter Billing Provider

 

b

Billing Other ID

 

 

Claim -F1 tab, 1 Claim tab, enter Billing Provider




*

 

Information on the Patient -F2 tab, 1 Insured tab OR 2 Other Insured tab

 

 

If any information on these two screens have been changed after its initial entry,

 

 

update the information and go to 4 Misc. Info tab, check B, and click Save.

 

NA

 

Claim - Not Found

 

 

One or more are incorrect, fix and rescore.  Patient Name (box 2), DOB (box 3), and DOS (box 24a).

 

 

See page 71 of this manual for a detailed description.

 

 

 

NA

 

Charge – Not Found

 

 

1 or more are incorrect, fix and rescore.  DOS (box 24a) and Charges (24d).

 

 

See page 70 of this manual for a detailed description.