1500 CMS Options (2012)

Field	CMS1500 (2012) Description Exceptions: When Payer is Primary Tab
[1] Insured's program	Select one of the following options: <none> Blank Use Legacy Standards Current Program with X Current Program with P
[1a] Insured's ID number	Select one of the following options: <none> Blank Use Legacy Standards Current payer's insured's policy # Insured's override # if not blank; else insured's policy # Social Security Nbr Current payer's policy # + Plan Code
[2 and 4] Enable Commas	Select this option to delimit first, last, and middle initial by commas.
[4] Insured's name	Select one of the following options: 'SAME' if Medicare 2nd and patient addr = insured addr; else LastName FirstName MI of insured 'SAME' if Medicare 2nd/3rd and patient addr = insured addr; else LastName FirstName MI of insured 'SAME' if patient and insured are same; else Blank 'SAME' if patient and insured are same; else LastName FirstName MI of insured 'SAME' if patient and insured are same; else UCase(LastName FirstName MI of insured) Blank Blank if patient and insured are same; else LastName FirstName MI of insured Blank if patient and insured are same; else UCase(LastName FirstName MI of insured) Blank if patient and primary insured are same; else LastName FirstName MI of insured Insured employer name LastName FirstName MI of insured Name of payer UCase(LastName FirstName MI of insured) UCase(LastName FirstName of insured)
[9] Other insured's name	Select one of the following options: <none> Blank Insured's name if 2nd ins exists and not patient else SAME; if no 2nd ins blank Insured's name if 2nd ins is Medigap and not patient, else SAME; if not Medigap ins blank Use Legacy Standards
[9a] Other insured's group number	Select one of the following options: <none> Blank Current insured's group number Current insured's policy number if 2nd ins is Medigap 'MEDIGAP' + policy number for secondary else blank Secondary insured's group number Secondary insured's policy number Use Legacy Standards Note: This is the [9a] Other Insured's Policy or Group Number field on the claim form.
[9b] Other insured's DOB	Select one of the following options: <none> Blank if 2nd ins is Medigap MMDDCCYY and sex checked; else blank MMDDCCYY and sex checked Use Legacy Standards Note: This is the [9b] Reserved for NUCC Use field on the claim form.
[9c] Employer's name or school name	Select one of the following options: Addr1 City Zip of MG if MG is 2nd/3rd; else Insured's Emp Name of secondary Addr1 State Zip of MG if MG is 2nd/3rd; else Blank Addr1 State Zip of MG if MedigapID# is blank and MG is 2nd/3rd; else Blank Adr1 Adr2 St Zip of MG if MG is 2/3 and MedigapID# is blank, else Blank; else 2nd Ins Emp Name if no MG Adr1 Adr2 of MG if MG is 2/3; else Blank if MCD is 2/3; else Addr1 Addr2 of Sup if Sup is 2/3; else Blank Blank Insured's Emp Name of MG if MG is 2nd/3rd; else Insured's Emp Name of secondary Insured's Emp Name of primary Insured's Emp Name of primary if secondary is not Supplemental; else Blank Insured's Emp Name of secondary Insured's Emp Name of secondary if secondary insured diff from primary insured; else Blank Insured's Emp Name of secondary if secondary is not Medicare; else Blank Insured's Emp Name of secondary if secondary is not Supplemental; else Blank UCase(Insured's Emp Name of secondary) Note: This is the [ 9c] Reserved for NUCC Use field on the claim form.
[9d] Insurance plan name or program name	Select one of the following options: Blank If MG 2/3, use Name of MG if MedigapID# is blank, else use MedigapID# of MG; else Blank If MG 2/3, use Name of MG if MedigapID# is blank, else use MedigapID# of MG; else Name of 2nd payer If MG 2/3, use Name of MG if MedigapID# is blank, else use MedigapID# OfficeNbr Name of MG; else Blank If MG 2/3, use Name of MG if MedigapID# is blank, else use MedigapID# OfficeNbr of MG; else Blank MedigapID# [OfficeNbr, if present] Name of MG if MG is 2nd/3rd; else Name of 2nd payer MedigapID# of MG if MG is 2nd Name of MG if MG is 2/3; else Blank if MCD is 2/3; else Name of Sup if Sup is 2/3; else Blank Name of MG if MG is 2/3; else Name of 2nd payer Name of MG if MG is 2nd; else Blank Name of primary payer Name of primary payer if primary payer is not Medicare and not Medicaid; else Blank Name of secondary payer Name of secondary payer if secondary insured diff from primary insured; else Blank Name of secondary payer if secondary is not Medicare; else Blank Name of secondary payer if secondary is not Supplemental; else Blank UCase(Name of secondary payer)
[10d] Claim Codes	Select one of the following options: <none> Other Payer's Provider Individual number Other Payer's Provider Individual number if other payer is Medicare
[11] Insured's policy group or FECA number	Select one of the following options: Blank Blank if secondary payer is Medicare; else Insured ID from secondary payer Group # from primary payer Group # from primary payer if primary paid amt > 0 and Medicaid secondary; else Blank Group # from secondary payer & Insured ID # from secondary payer Insured ID # from primary payer if not blank; else Group # from primary payer MEDICAID & Insured ID of Medicaid payer if 2nd 3rd are either MCD, MGAP or MGAP, MCD; else NONE NONE NONE if no secondary UCase(Group # from primary payer) UCase(Insured ID # from primary payer) UCase(Insured ID # from primary payer) if Group # is blank; else UCase(Group # from primary payer) UCase(Insured ID # from primary payer) if not blank; else UCase(Group # from primary payer)
[11b] Other Claim ID	Select this option to print the other claim ID on the claim form.
[11c] Insurance plan name or program name	Select one of the following options: Blank Insured's ID # from primary Primary payer name Primary payer name if secondary insurance exists and insured is patient Secondary payer name if insured is patient Secondary payer name if secondary payer is not Medicare UCase(primary payer name)
[11d] Is there another health plan?	Select one of the following options: Blank Blank if secondary is Medicaid, Medigap, Supplemental, or empty; else No Blank if secondary is Medicare; else No No Yes if other payers exist; else Blank Yes if other payers exist; else No
[24j Enable group logic] if Prov ID is selected in box 24k BELOW, display Prov ID only if the provider belongs to a group. If the provider is not in a group and Prov ID is selected, display nothing.	Select this option to do the following: If the Prov ID option is selected in box 24k TOP, listed below, display Prov ID only if the provider belongs to a group. If the provider is not in a group and Prov ID is selected, display nothing.
[24j] Reserved for local use	Select one of the following options: <none> Allow or Deduct Amt $$.==/$$== (excluding DME) For example: if the allowed amount is $100 and deductible amount is $200, 100.00/20000 will print; or if the allowed amount is zero, 0.00/20000 will print. Allowed Amt Only (excluding DME) Blank Group Number Group Number (excluding DME) Narrative (excluding DME) OptClaimValue1 (excluding DME) OptClaimValue2 (excluding DME) Prior Paid Amt ($$.==) (excluding DME) Prior Paid Amt ($$.== - no'.') (excluding DME) Prior Paid Amt Other Than Medicare ($$¢¢ - no'.') (excluding DME) Prov ID Prov ID (excluding DME) Right 6 digits of Prov ID (excluding DME) UCase(Prov ID) (excluding DME) UCase(Prov St Lic #) (excluding DME) UPIN
[29] Amount Paid	Select one of the following options: Blank Blank if no other payers; else Sec + Ter paid amt if total paid amt > 0, else 1.00 Pat paid amt Pat paid amt if sec payer None/Medicaid/MediGap/Supplemental; else Blank Pri + Sec + Ter + Pat paid amt Pri + Sec + Ter paid amt Pri paid amt Sec (if not Medicare) + Ter + Pat paid amt if encounter has non-Medicare/Medicaid payers; else Blank Sec (if not Medicare) + Ter paid amt Sec + Ter + Pat paid amt Sec + Ter paid amt
[30] Balance Due	Select one of the following options: Blank Blank if secondary payer is Medicare; else Box 28 minus Box 29 Blank if secondary payer is None/Medicaid/MediGap/Supplemental; else Box 28 minus Box 29 Box 28 minus [secondary (if Medicare) + tertiary + patient paid amt] Box 28 minus all pymts (ins and pat) + common rules adj and ref settings Box 28 minus Box 29

[1] Insured's program

Select one of the following options:

<none>
Blank
Use Legacy Standards
Current Program with X
Current Program with P

[1a] Insured's ID number

Select one of the following options:

<none>
Blank
Use Legacy Standards
Current payer's insured's policy #
Insured's override # if not blank; else insured's policy #
Social Security Nbr
Current payer's policy # + Plan Code

[2 and 4] Enable Commas

Select this option to delimit first, last, and middle initial by commas.

[4] Insured's name

Select one of the following options:

'SAME' if Medicare 2nd and patient addr = insured addr; else LastName FirstName MI of insured
'SAME' if Medicare 2nd/3rd and patient addr = insured addr; else LastName FirstName MI of insured
'SAME' if patient and insured are same; else Blank
'SAME' if patient and insured are same; else LastName FirstName MI of insured
'SAME' if patient and insured are same; else UCase(LastName FirstName MI of insured)
Blank
Blank if patient and insured are same; else LastName FirstName MI of insured
Blank if patient and insured are same; else UCase(LastName FirstName MI of insured)
Blank if patient and primary insured are same; else LastName FirstName MI of insured
Insured employer name
LastName FirstName MI of insured
Name of payer
UCase(LastName FirstName MI of insured)
UCase(LastName FirstName of insured)

[9] Other insured's name

Select one of the following options:

<none>
Blank
Insured's name if 2nd ins exists and not patient else SAME; if no 2nd ins blank
Insured's name if 2nd ins is Medigap and not patient, else SAME; if not Medigap ins blank
Use Legacy Standards

[9a] Other insured's group number

Select one of the following options:

<none>
Blank
Current insured's group number
Current insured's policy number
if 2nd ins is Medigap 'MEDIGAP' + policy number for secondary else blank
Secondary insured's group number
Secondary insured's policy number
Use Legacy Standards
Note: This is the [9a] Other Insured's Policy or Group Number field on the claim form.

[9b] Other insured's DOB

Select one of the following options:

<none>
Blank
if 2nd ins is Medigap MMDDCCYY and sex checked; else blank
MMDDCCYY and sex checked
Use Legacy Standards
Note: This is the [9b] Reserved for NUCC Use field on the claim form.

[9c] Employer's name or school name

Select one of the following options:

Addr1 City Zip of MG if MG is 2nd/3rd; else Insured's Emp Name of secondary
Addr1 State Zip of MG if MG is 2nd/3rd; else Blank
Addr1 State Zip of MG if MedigapID# is blank and MG is 2nd/3rd; else Blank
Adr1 Adr2 St Zip of MG if MG is 2/3 and MedigapID# is blank, else Blank; else 2nd Ins Emp Name if no MG
Adr1 Adr2 of MG if MG is 2/3; else Blank if MCD is 2/3; else Addr1 Addr2 of Sup if Sup is 2/3; else Blank
Blank
Insured's Emp Name of MG if MG is 2nd/3rd; else Insured's Emp Name of secondary
Insured's Emp Name of primary
Insured's Emp Name of primary if secondary is not Supplemental; else Blank
Insured's Emp Name of secondary
Insured's Emp Name of secondary if secondary insured diff from primary insured; else Blank
Insured's Emp Name of secondary if secondary is not Medicare; else Blank
Insured's Emp Name of secondary if secondary is not Supplemental; else Blank
UCase(Insured's Emp Name of secondary)
Note: This is the [ 9c] Reserved for NUCC Use field on the claim form.

[9d] Insurance plan name or program name

Select one of the following options:

Blank
If MG 2/3, use Name of MG if MedigapID# is blank, else use MedigapID# of MG; else Blank
If MG 2/3, use Name of MG if MedigapID# is blank, else use MedigapID# of MG; else Name of 2nd payer
If MG 2/3, use Name of MG if MedigapID# is blank, else use MedigapID# OfficeNbr Name of MG; else Blank
If MG 2/3, use Name of MG if MedigapID# is blank, else use MedigapID# OfficeNbr of MG; else Blank
MedigapID# [OfficeNbr, if present] Name of MG if MG is 2nd/3rd; else Name of 2nd payer
MedigapID# of MG if MG is 2nd
Name of MG if MG is 2/3; else Blank if MCD is 2/3; else Name of Sup if Sup is 2/3; else Blank
Name of MG if MG is 2/3; else Name of 2nd payer
Name of MG if MG is 2nd; else Blank
Name of primary payer
Name of primary payer if primary payer is not Medicare and not Medicaid; else Blank
Name of secondary payer
Name of secondary payer if secondary insured diff from primary insured; else Blank
Name of secondary payer if secondary is not Medicare; else Blank
Name of secondary payer if secondary is not Supplemental; else Blank
UCase(Name of secondary payer)

[10d] Claim Codes

Select one of the following options:

<none>
Other Payer's Provider Individual number
Other Payer's Provider Individual number if other payer is Medicare

[11] Insured's policy group or FECA number

Select one of the following options:

Blank
Blank if secondary payer is Medicare; else Insured ID from secondary payer
Group # from primary payer
Group # from primary payer if primary paid amt > 0 and Medicaid secondary; else Blank
Group # from secondary payer & Insured ID # from secondary payer
Insured ID # from primary payer if not blank; else Group # from primary payer
MEDICAID & Insured ID of Medicaid payer if 2nd 3rd are either MCD, MGAP or MGAP, MCD; else NONE
NONE
NONE if no secondary
UCase(Group # from primary payer)
UCase(Insured ID # from primary payer)
UCase(Insured ID # from primary payer) if Group # is blank; else UCase(Group # from primary payer)
UCase(Insured ID # from primary payer) if not blank; else UCase(Group # from primary payer)

[11b] Other Claim ID

Select this option to print the other claim ID on the claim form.

[11c] Insurance plan name or program name

Select one of the following options:

Blank
Insured's ID # from primary
Primary payer name
Primary payer name if secondary insurance exists and insured is patient
Secondary payer name if insured is patient
Secondary payer name if secondary payer is not Medicare
UCase(primary payer name)

[11d] Is there another health plan?

Select one of the following options:

Blank
Blank if secondary is Medicaid, Medigap, Supplemental, or empty; else No
Blank if secondary is Medicare; else No
No
Yes if other payers exist; else Blank
Yes if other payers exist; else No

[24j Enable group logic] if Prov ID is selected in box 24k BELOW, display Prov ID only if the provider belongs to a group. If the provider is not in a group and Prov ID is selected, display nothing.

Select this option to do the following:

If the Prov ID option is selected in box 24k TOP, listed below, display Prov ID only if the provider belongs to a group.
If the provider is not in a group and Prov ID is selected, display nothing.

[24j] Reserved for local use

Select one of the following options:

<none>
Allow or Deduct Amt $$.==/$$== (excluding DME)
For example: if the allowed amount is $100 and deductible amount is $200, 100.00/20000 will print; or if the allowed amount is zero, 0.00/20000 will print.
Allowed Amt Only (excluding DME)
Blank
Group Number
Group Number (excluding DME)
Narrative (excluding DME)
OptClaimValue1 (excluding DME)
OptClaimValue2 (excluding DME)
Prior Paid Amt ($$.==) (excluding DME)
Prior Paid Amt ($$.== - no'.') (excluding DME)
Prior Paid Amt Other Than Medicare ($$¢¢ - no'.') (excluding DME)
Prov ID
Prov ID (excluding DME)
Right 6 digits of Prov ID (excluding DME)
UCase(Prov ID) (excluding DME)
UCase(Prov St Lic #) (excluding DME)
UPIN

[29] Amount Paid

Select one of the following options:

Blank
Blank if no other payers; else Sec + Ter paid amt if total paid amt > 0, else 1.00
Pat paid amt
Pat paid amt if sec payer None/Medicaid/MediGap/Supplemental; else Blank
Pri + Sec + Ter + Pat paid amt
Pri + Sec + Ter paid amt
Pri paid amt
Sec (if not Medicare) + Ter + Pat paid amt if encounter has non-Medicare/Medicaid payers; else Blank
Sec (if not Medicare) + Ter paid amt
Sec + Ter + Pat paid amt
Sec + Ter paid amt

[30] Balance Due

Select one of the following options:

Blank
Blank if secondary payer is Medicare; else Box 28 minus Box 29
Blank if secondary payer is None/Medicaid/MediGap/Supplemental; else Box 28 minus Box 29
Box 28 minus [secondary (if Medicare) + tertiary + patient paid amt]
Box 28 minus all pymts (ins and pat) + common rules adj and ref settings
Box 28 minus Box 29

1500 CMS Options (2012)

Recommendations

1500 CMS Options (2012)

CMS 1500 (2012)

CMS 1500 (2012)

1500 CMS Options (2012)

1500 CMS Options (2012)

CMS 1500 (2005) Options

1500 CMS Options (2012)

CMS 1500 (2012)

CMS 1500 (2012)

1500 CMS Options (2012)

1500 CMS Options (2012)

CMS 1500 (2005) Options