CMS 1500 (2005) Options

Field	CMS 1500 (2005) Options Description Common Rules Tab
About Field Prefixes	Fields can have a prefix of UCase, LTrim, RTrim, or Trim. All fields with a prefix of: UCase - display in upper case LTrim - all leading spaces are removed RTrim - all trailing spaces are removed Trim - all leading and trailing spaces are removed
Do not print payer address on CMS	Select this option to prevent the payer address from printing on the CMS form.
Payer Name at top of form	Select one of the following Payer Name format options: Blank Payer Alias Payer Alias - Upper Case Payer Name Payer Name - Upper Case Use Contents of Box 19
Print payer address in old location	Select this option to print the address in the upper-right corner of the form.
Print page numbers on multiple page claims	Select this option to print the page numbers in the format of Page XX of YY at the top of multiple page claims. Page numbers do not print on single page claims.
[1] Insured's program	Select one of the following options: Blank Use Legacy Standards Current Program with X Current Program with P
[1a] Insured's ID number	Select one of the following options: 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
[10bc] Force 10b & 10c to No	Select this option for Worker's Comp claims to force box 10b and 10c to be set to No. Only box 10a Employment will be checked.
[10d] Reserved for Local Use	Select one of the following options: Blank Other Payer's Provider Individual number Other Payer's Provider Individual number if other payer is Medicare "MDC" + Insured ID if any Other Payers Medicaid "01" Sum of Other Payers Amount Paid "Y" if Emergency CPT4 "ATTACHMENT" Insured ID if any Other Payers Medicaid EPSDT Referral Codes Referring Physician UPIN
[11a] Date format for insured's date of birth	Select one of the following date format options: Blank MMDDYY MMDDYYYY
[11a] Display insured's sex	Select this option to display the insured's sex in box 11a.
[15] Date format for patient same illness	Select one of the following date format options: Blank MMDDYY MMDDYYYY N/A
[17] Name of referring physician or other source	Select one of the following options: Blank First, MI, Last Name of Referring Provider (no commas) First, MI, Last Name of Referring Provider plus state (no commas) Last First Last First Middle Initial Last First Middle Initial State Last First State Last, First Last, First State Referring name, else 'None' Self Referral if no referring doctor UCASE(First MI Last Name of Referring Provider (no commas)) UCASE(First MI Last Name of Referring Provider plus state (no commas)) UCase(Last First Middle Initial) UCase(Last First Middle Initial) State UCase(Last First) UCase(Last First) State
[17a] ID number of referring physician	Select one of the following options: Referring Phys Taxonomy Code Blank Georgia Better Health Nbr Physician State License Nbr Prior Authorization Nbr Referral Number Referring Physician ID Nbr Referring UPIN, else 'None' Use Legacy Standards
[17b] NPI	Select one of the following options: Blank Referring Provider's NPI
[19] Display qualifier	Select this option to print the qualifier before the data with no spaces between the qualifier and the data.
[19] Reserved Local Use	Select one of the following options: Anesthesia (Start/Stop) and/or Prior Deductible and/or Narrative Anesthesia Time (24h format), else Narrative Anesthesia Time (CAPS with total), else Narrative Anesthesia Time (with 'Start'/'Stop'), else Narrative Authorization Number, else Narrative Blank EPSDT Referral Condition Codes, else Narrative Legacy Option Narrative only NDC code, else Narrative If you enable this claim print option and the NDC information is in the SIM Library, then the National Drug Code prints only in Box 19 of the 1500 claim form followed by the line it is referencing. For example, 00169706101 Line 2. However, if you enable this option and the NDC information is not in the SIM Library, then any existing charge narrative prints in Box 19. For complete information about enabling NDC for electronic and paper claims, see NDC Coding in the Claims User Guide for NextGen® Enterprise PM. Prior Deductible Prior Deductible and Narrative Referral Number Referring UPIN and Date Last Seen, else Narrative Supervisor ID and NPI (prints with one space between the numbers) Supervisor ID and NPI; else narrative Note: If an option is selected and it does not exist on the encounter or no option is selected, the narrative is the default value.
[19] Use two lines for text	Select this option to force the application to use two lines for text in box 19.
[21] Diagnosis or nature of illness or injury	Select one of the following options: Blank Code Description
[22] Medicaid resubmission code	Select one of the following options: Blank Deductible Amount for all line items if primary/secondary is MCR; else Blank Prov ID ResubCode (from Claim Maintenance) Supervising Prov ID UCase(ResubCode) UCase(ResubRefNbr) (from Claim Maintenance) UCase(ResubCode) (from Claim Maintenance)
[22] Original ref. no.	Select one of the following options: Blank Paid amount if primary/secondary is MCR; else Blank Prov ID Resub Ref # (from Claim Maintenance) Supervising Prov ID
[23] Authorization number	Select one of the following options: Authorization Number Authorization Number - Upper Case Blank CLIA Number CLIA Number - Upper Case Legacy Option Medicare Provider Number Medicare Provider Number - Upper Case Referral Number Rendering Provider Name (Supervisor Billing only)
[24] Display supplemental data qualifier	Select this option to print the qualifier. If this option is checked, but there is no supplemental information to print on the claim, the qualifier does not print. The default value is checked.
[24] Supplemental charge-related data to display above line	Select one of the following options: Anesthesia Begin/End (7) Anesthesia Begin/End/Time (7) Blank Charge Narrative (ZZ) NDC desc/basis of measure/drug units(N4) NDC desc/basis of measure/drug units(N4), else Anesthesia begin/end(7), else Narrative(ZZ) NDC desc/basis of measure/drug units(N4), else Anesthesia begin/end/time(7), else Narrative(ZZ) Service Item Description (ZZ) The supplemental description information prints in the shaded area above the charge line. The qualifier in parentheses prints in front of the information without any spaces between the qualifier and the information.
[24a] Date format for dates of service	Select one of the following formats: MM DD YY MM DD YYYY MMDDYY MMDDYYYY
[24a] Force 2 digit year on output to file	Select this option to format the year as two digits when printing to a file.
[24c] EMG Indicator	Select one of the following options for the Emergency Indicator: Actual Value (Y/N) Blank Remap Y = 1, N = Blank Remap Y = 1, N = N Remap Y = X, N = Blank Remap Y = X, N = N Remap Y = Y, N = Blank Note: The Remap options enable you to substitute a specific character in place of the Y or N.
[24d] Modifier Options for Box 24d	Select one of the following options: Blank Print 99 in 24d and modifiers in Box 19 when more than one modifier Print 99 in 24d when more than one modifier Print all modifiers Print only 3 modifiers Print xx 99 in 24d and modifiers in Box 19 when more than two modifiers Print xx 99 in 24d when more than two modifiers Note: When Blank is selected, all modifiers print on the claim.
[24e] Diagnosis code	Select one of the following options: All Pointers (each line item contains pointers (1-4) to all the primary diagnoses selected in the encounter) All Pointers without commas Blank Diag Code (listed for each line item) Diag Code without decimals Frmttd Code (nnn/nnn.n/nnn.nn) (each line item shows the diagnosis formatted as a 3 digit code without decimals or a 4 or 5 digit code with decimals) Primary Pointer (each line item contains a pointer (1-4) to the primary diagnosis in box 21)
[24f] Suppress commas in amount	Select this option to suppress the commas in the amount in box 24f. It also suppresses the commas in box 28. Box 28 is the sum of box 24f charges.
[24g] Display days/units	Select one of the following options to display the number of anesthesia days or units in Box 24g: Anes Min if Anes SIM else Quantity (Units) Anes Time (HMM) if Anes SIM else Quantity (Units) – For example, 30 minutes would be 030, 60 minutes would be 100, and 75 minutes would be 115. Anes Units if Anes SIM else Quantity (Units) Anesthesia Min if Anes SIM and Alt Code populated else Anes Units if Anes SIM else Quantity (Units) Blank Quantity (Units) Time Units if Anes SIM else Quantity (Units)
[24h top] EPSDT	Select one of the following options: Blank EPSDT Code Legacy Option Note: If you want a Y or N to print in box 24h, you must set this up on the Claims tab on the Encounter Maintenance window. In the EPSDT Encounter Code - Paper field, select Other. A text box displays to the right of this field. Enter Y or N in this box.
[24h bottom] Family Planning	Select one of the following options: Blank Family Planning Code Legacy Option
[24i] ID qualifier	Select this option to print the two-character qualifier that identifies the rendering provider in box 24j. If the rendering provider ID # in box 24j is blank, the qualifier is also blank. The qualifier is populated from the payer master file.
[24j TOP - Enable group logic] If Prov ID is selected in box 24j TOP 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 24j 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 TOP] Rendering Provider ID	Select one of the following information options: Allow or Deduct Amt $$.==/$$== (excluding DME) 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) Prov Taxonomy Code Right 6 digits of Prov ID (excluding DME) UCase(Prov ID) (excluding DME) UCase(Prov St Lic #) (excluding DME) UPIN
[24j Bottom] Rendering NPI	Select one of the following options: Blank Rendering NPI Rendering NPI if provider belongs to a group, else blank
[25] Federal tax ID number	Select one of the following options: Blank Prov ID Tax ID UCase(Tax ID)
[25] Federal tax ID number type	Select one of the following options: Blank EIN Read from claim (standard) SSN
[27] Accept Assignment/Worker's Comp	Select one of the following options to indicate how to select the Accept Assignment box (Box 27): Blank – select nothing No – select No Use Legacy Options – use previous settings Yes – select Yes
[29] Amount Paid - Include adjustments for payers?	Select this option to display adjustments for payers on the CMS 1500 claim.
[29] Amount Paid - Include refunds for payers?	Select this option to include refunds in payer amount.
[29] Amount Paid - When zero dollar amount, display:	Select one of the following options: 0.00 Blank
[29] Amount Paid - Format	Select one of the following options: 999,999.99 999999.99
[30] Balance Due - When zero dollar amount, display:	Select one of the following options: 0.00 Blank
[30] Balance Due - Format	Select one of the following options: 999,999.99 999999.99
[30] Balance Due - Include Adjustments	Select one of the following options: Ignore Adjustments Include Adjustments of All Payers Include Adjustments of Current Payer Include Adjustments of Prior and Current Payer Include Adjustments of Prior Payer Use Box 29 setting
[30] Balance Due - Include Refunds	Select one of the following options: <None> Ignore Refunds Include Refunds for All Payers Use Box 29 setting
[29 & 30] Amount Paid & Balance Due - Total Location	Select one of the following options to indicate where to print the total amount paid for multi-page claims: Grand total on first page only; blank on other pages Grand total on last page only; 'page X of Y' on other pages Grand total on last page only; blank on other pages Total each page separately; no grand total
[31-1] Signature of physician or supplier	This claim printing option must have an option selected from the drop-down list. The option that is selected prints on the CMS 1500 box 31. The options available include: ‘Agreement on File’ 'COMPUTER-GENERATED MM/DD/YY' ‘signature on file’ ‘SIGNATURE ON FILE’ (upper case) Blank Current Date (mm/dd/yy} Current Date (mm/dd/yyyy) Group Name Name of facility/location Original Date (mm/dd/yy) Original Date (mm/dd/yyyy) Physician License Number Provider Individual Number Rendering name (Display As) RENDERING NAME (Display As - Upper Case) Rendering name (Last, First MI) Rendering name (Last, First MI - Upper Case)
[31-2] Signature of physician or supplier	This claim printing option must have an option selected from the drop-down list. The option that is selected prints on the CMS 1500 box 31. The options available include: ‘Agreement on File’ 'COMPUTER-GENERATED MM/DD/YY' ‘signature on file’ ‘SIGNATURE ON FILE’ (upper case) Blank Current Date (mm/dd/yy} Current Date (mm/dd/yyyy) Original Date (mm/dd/yy) Original Date (mm/dd/yyyy) Physician License Number Provider Individual Number Rendering name (Display As) RENDERING NAME (Display As - Upper Case) Rendering name (Last, First MI) Rendering name (Last, First MI - Upper Case)
[31-3] Signature of physician or supplier	This claim printing option must have an option selected from the drop-down list. The option that is selected prints on the CMS 1500 box 31. The options available include: ‘Agreement on File’ 'COMPUTER-GENERATED MM/DD/YY' ‘signature on file’ ‘SIGNATURE ON FILE’ (upper case) Blank Current Date (mm/dd/yy - right justified} Current Date (mm/dd/yyyy) Original Date (mm/dd/yy) Original Date (mm/dd/yyyy) Physician License Number Provider Individual Number Rendering name (Display As) RENDERING NAME (Display As - Upper Case) Rendering name (Last, First MI) Rendering name (Last, First MI - Upper Case)
[32] COB1 Recent Paid Date or Batch Nbr below box	Select one of the following options: Batch Nbr Blank Recent Date Recent Date & Batch Nbr
[32] Convert values to upper case	Select this option to force all values in box 32, lines 1-4, to appear in upper case on the CMS1500 claim.
[32-1] Name/Addr where services rendered	Select one of the following options: 'SAME' if phys addr = fac/loc addr; else Name of fac/loc 'SAME' if phys name/addr = fac/loc & POS is office/inpat hosp; else Name of fac/loc "SAME' if phys name/addr = fac/loc name/addr; else Name of fac/loc Blank Blank if phys addr = fac/loc addr; else Name of fac/loc Blank if phys name/addr = fac/loc name/addr; else Name of fac/loc Blank if POS is office; else Name of fac/loc Blank if POS is office; Facility Name if not blank; else Practice Name Facility Name if not blank; else Practice Name Name of facility/location
[32-2] Name/Addr where services rendered	Select one of the following options: Addr1 Addr2 of facility/location Blank Blank if phys addr = fac/loc addr; else Addr1 Addr2 of fac/loc Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Addr1 Addr2 of fac/loc Blank if phys name/addr = fac/loc name/addr; else Addr1 Addr2 of fac/loc Blank if POS is office; else Addr1 Addr2 of fac/loc
[32-3] Name/Addr where services rendered	Select one of the following options: Blank Blank if phys addr = fac/loc addr; else City State Zip of fac/loc Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else City St Zip of fac/loc Blank if phys name/addr = fac/loc name/addr; else City State Zip of fac/loc Blank if POS is office; else City State Zip of fac/loc City State Zip of facility/location
[32-a] NPI	Select one of the following options: Blank Blank if phys addr = fac/loc addr; else Fac NPI Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Fac NPI Blank if phys name/addr = fac/loc; else Fac NPI Blank if POS is office; else Fac NPI Facility NPI
[32-b] Facility ID	Select one of the following options: Blank Blank if phys addr = fac/loc addr; else Fac ID (if present), else Mammography Cert of loc Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Fac ID, else Mam Cert Blank if phys name/addr = fac/loc; else Fac ID (if present), else Mammography Cert of loc Blank if POS is office; else Fac ID (if present), else Mammography Cert of loc Facility ID (if present), else Mammography Cert of location Facility Taxonomy
[32-b & 33-b] Add space between qualifier and data	Select this option to add a space between the qualifier and the data for boxes 32-b and 33-b.
[33] Display group phone #	Select this option to print the group phone number of the billing provider in the top right corner of box 33.
[33-1] Physician's/Supplier's information	Select one of the following options: Group Name UCase(Group Name) Group Phone SAME Supervising Name if supervising exists and is not blank; else Rendering Name Supervising Phone if supervising exists and is not blank; else Rendering Phone
[33-2] Physician's/Supplier's information	Select one of the following options: Group Addr1 & Addr2 UCase(Group Addr1 & Addr2) UCase(Group Name) Blank Supervising Addr1 & Addr2 if supervising exists and is not blank; else Rendering Addr1 & Addr2 Supervising Name if supervising exists and is not blank; else Rendering Name
[33-3] Physician's/Supplier's information	Select one of the following options: Group City & St & Zip UCase(Group City & St & Zip) UCase(Group Addr1 & Addr2) Blank Supervising City & St & Zip if supervising exists and is not blank; else Rendering City & St & Zip Supervising Addr1 & Addr2 if supervising exists and is not blank; else Rendering Addr1 & Addr2
[33-4] Physician's/Supplier's information	Select one of the following options: Blank UCase(Group City & St & Zip) Group Phone Supervising City & St & Zip if supervising exists and is not blank; else Rendering City & St & Zip Supervising Phone if supervising exists and is not blank; else Rendering Phone
[33-a] Display NPI	Select one of the following options: Blank NPI (group NPI if group billing, else provider individual NPI if billing as an individual)
[33-b Enable group logic] If Group # or Prov ID is selected in Box 33-b BELOW, display Group # only if the provider belongs to a group (Group # selected) or Prov ID if the provider does not belong to a group (Prov ID selected). If the provider is in a group and Prov ID is selected, display nothing.	Select this option to activate the following logic: If Group # or Prov ID is selected in box 33 b BELOW, display Group # only if the provider belongs to a group (Group # selected) or Prov ID if the provider does not belong to a group (Prov ID selected). If the provider is in a group and Prov ID is selected, display nothing. If the provider is not in a group and Group # is selected, display nothing.
[33-b] Physician's/Supplier's information	Select one of the following options: Group # Prov ID & OptClaimValue1 Blank OptClaimValue1 OptClaimValue2 Prov ID & OptClaimValue2 Group Opt Val Prov Taxonomy code Group Taxonomy code Phys Billing Taxonomy code State License Nbr UCase(Group #) Trim(Group #) UCase(Trim(Group #) Prov ID Trim(Prov ID) UCase(Trim(Prov ID) Prov ID & Prov Tax ID Prov ID & Group #

About Field Prefixes

Fields can have a prefix of UCase, LTrim, RTrim, or Trim. All fields with a prefix of:

UCase - display in upper case
LTrim - all leading spaces are removed
RTrim - all trailing spaces are removed
Trim - all leading and trailing spaces are removed

Do not print payer address on CMS

Select this option to prevent the payer address from printing on the CMS form.

Payer Name at top of form

Select one of the following Payer Name format options:

Blank
Payer Alias
Payer Alias - Upper Case
Payer Name
Payer Name - Upper Case
Use Contents of Box 19

Print payer address in old location

Select this option to print the address in the upper-right corner of the form.

Print page numbers on multiple page claims

Select this option to print the page numbers in the format of Page XX of YY at the top of multiple page claims. Page numbers do not print on single page claims.

[1] Insured's program

Select one of the following options:

Blank
Use Legacy Standards
Current Program with X
Current Program with P

[1a] Insured's ID number

Select one of the following options:

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

[10bc] Force 10b & 10c to No

Select this option for Worker's Comp claims to force box 10b and 10c to be set to No. Only box 10a Employment will be checked.

[10d] Reserved for Local Use

Select one of the following options:

Blank
Other Payer's Provider Individual number
Other Payer's Provider Individual number if other payer is Medicare
"MDC" + Insured ID if any Other Payers Medicaid
"01"
Sum of Other Payers Amount Paid
"Y" if Emergency CPT4
"ATTACHMENT"
Insured ID if any Other Payers Medicaid
EPSDT Referral Codes
Referring Physician UPIN

[11a] Date format for insured's date of birth

Select one of the following date format options:

Blank
MMDDYY
MMDDYYYY

[11a] Display insured's sex

Select this option to display the insured's sex in box 11a.

[15] Date format for patient same illness

Select one of the following date format options:

Blank
MMDDYY
MMDDYYYY
N/A

[17] Name of referring physician or other source

Select one of the following options:

Blank
First, MI, Last Name of Referring Provider (no commas)
First, MI, Last Name of Referring Provider plus state (no commas)
Last First
Last First Middle Initial
Last First Middle Initial State
Last First State
Last, First
Last, First State
Referring name, else 'None'
Self Referral if no referring doctor
UCASE(First MI Last Name of Referring Provider (no commas))
UCASE(First MI Last Name of Referring Provider plus state (no commas))
UCase(Last First Middle Initial)
UCase(Last First Middle Initial) State
UCase(Last First)
UCase(Last First) State

[17a] ID number of referring physician

Select one of the following options:

Referring Phys Taxonomy Code
Blank
Georgia Better Health Nbr
Physician State License Nbr
Prior Authorization Nbr
Referral Number
Referring Physician ID Nbr
Referring UPIN, else 'None'
Use Legacy Standards

[17b] NPI

Select one of the following options:

Blank
Referring Provider's NPI

[19] Display qualifier

Select this option to print the qualifier before the data with no spaces between the qualifier and the data.

[19] Reserved Local Use

Select one of the following options:

Anesthesia (Start/Stop) and/or Prior Deductible and/or Narrative
Anesthesia Time (24h format), else Narrative
Anesthesia Time (CAPS with total), else Narrative
Anesthesia Time (with 'Start'/'Stop'), else Narrative
Authorization Number, else Narrative
Blank
EPSDT Referral Condition Codes, else Narrative
Legacy Option
Narrative only
NDC code, else Narrative
If you enable this claim print option and the NDC information is in the SIM Library, then the National Drug Code prints only in Box 19 of the 1500 claim form followed by the line it is referencing. For example, 00169706101 Line 2. However, if you enable this option and the NDC information is not in the SIM Library, then any existing charge narrative prints in Box 19. For complete information about enabling NDC for electronic and paper claims, see NDC Coding in the Claims User Guide for NextGen® Enterprise PM.
Prior Deductible
Prior Deductible and Narrative
Referral Number
Referring UPIN and Date Last Seen, else Narrative
Supervisor ID and NPI (prints with one space between the numbers)
Supervisor ID and NPI; else narrative

Note: If an option is selected and it does not exist on the encounter or no option is selected, the narrative is the default value.

[19] Use two lines for text

Select this option to force the application to use two lines for text in box 19.

[21] Diagnosis or nature of illness or injury

Select one of the following options:

Blank
Code
Description

[22] Medicaid resubmission code

Select one of the following options:

Blank
Deductible Amount for all line items if primary/secondary is MCR; else Blank
Prov ID
ResubCode (from Claim Maintenance)
Supervising Prov ID
UCase(ResubCode) UCase(ResubRefNbr) (from Claim Maintenance)
UCase(ResubCode) (from Claim Maintenance)

[22] Original ref. no.

Select one of the following options:

Blank
Paid amount if primary/secondary is MCR; else Blank
Prov ID
Resub Ref # (from Claim Maintenance)
Supervising Prov ID

[23] Authorization number

Select one of the following options:

Authorization Number
Authorization Number - Upper Case
Blank
CLIA Number
CLIA Number - Upper Case
Legacy Option
Medicare Provider Number
Medicare Provider Number - Upper Case
Referral Number
Rendering Provider Name (Supervisor Billing only)

[24] Display supplemental data qualifier

Select this option to print the qualifier. If this option is checked, but there is no supplemental information to print on the claim, the qualifier does not print. The default value is checked.

[24] Supplemental charge-related data to display above line

Select one of the following options:

Anesthesia Begin/End (7)
Anesthesia Begin/End/Time (7)
Blank
Charge Narrative (ZZ)
NDC desc/basis of measure/drug units(N4)
NDC desc/basis of measure/drug units(N4), else Anesthesia begin/end(7), else Narrative(ZZ)
NDC desc/basis of measure/drug units(N4), else Anesthesia begin/end/time(7), else Narrative(ZZ)
Service Item Description (ZZ)

The supplemental description information prints in the shaded area above the charge line. The qualifier in parentheses prints in front of the information without any spaces between the qualifier and the information.

[24a] Date format for dates of service

Select one of the following formats:

MM DD YY
MM DD YYYY
MMDDYY
MMDDYYYY

[24a] Force 2 digit year on output to file

Select this option to format the year as two digits when printing to a file.

[24c] EMG Indicator

Select one of the following options for the Emergency Indicator:

Actual Value (Y/N)
Blank
Remap Y = 1, N = Blank
Remap Y = 1, N = N
Remap Y = X, N = Blank
Remap Y = X, N = N
Remap Y = Y, N = Blank

Note: The Remap options enable you to substitute a specific character in place of the Y or N.

[24d] Modifier Options for Box 24d

Select one of the following options:

Blank
Print 99 in 24d and modifiers in Box 19 when more than one modifier
Print 99 in 24d when more than one modifier
Print all modifiers
Print only 3 modifiers
Print xx 99 in 24d and modifiers in Box 19 when more than two modifiers
Print xx 99 in 24d when more than two modifiers

Note: When Blank is selected, all modifiers print on the claim.

[24e] Diagnosis code

Select one of the following options:

All Pointers (each line item contains pointers (1-4) to all the primary diagnoses selected in the encounter)
All Pointers without commas
Blank
Diag Code (listed for each line item)
Diag Code without decimals
Frmttd Code (nnn/nnn.n/nnn.nn) (each line item shows the diagnosis formatted as a 3 digit code without decimals or a 4 or 5 digit code with decimals)
Primary Pointer (each line item contains a pointer (1-4) to the primary diagnosis in box 21)

[24f] Suppress commas in amount

Select this option to suppress the commas in the amount in box 24f. It also suppresses the commas in box 28. Box 28 is the sum of box 24f charges.

[24g] Display days/units

Select one of the following options to display the number of anesthesia days or units in Box 24g:

Anes Min if Anes SIM else Quantity (Units)
Anes Time (HMM) if Anes SIM else Quantity (Units) – For example, 30 minutes would be 030, 60 minutes would be 100, and 75 minutes would be 115.
Anes Units if Anes SIM else Quantity (Units)
Anesthesia Min if Anes SIM and Alt Code populated else Anes Units if Anes SIM else Quantity (Units)
Blank
Quantity (Units)
Time Units if Anes SIM else Quantity (Units)

[24h top] EPSDT

Select one of the following options:

Blank
EPSDT Code
Legacy Option

Note: If you want a Y or N to print in box 24h, you must set this up on the Claims tab on the Encounter Maintenance window. In the EPSDT Encounter Code - Paper field, select Other. A text box displays to the right of this field. Enter Y or N in this box.

[24h bottom] Family Planning

Select one of the following options:

Blank
Family Planning Code
Legacy Option

[24i] ID qualifier

Select this option to print the two-character qualifier that identifies the rendering provider in box 24j. If the rendering provider ID # in box 24j is blank, the qualifier is also blank. The qualifier is populated from the payer master file.

[24j TOP - Enable group logic] If Prov ID is selected in box 24j TOP 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 24j 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 TOP] Rendering Provider ID

Select one of the following information options:

Allow or Deduct Amt $$.==/$$== (excluding DME)
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)
Prov Taxonomy Code
Right 6 digits of Prov ID (excluding DME)
UCase(Prov ID) (excluding DME)
UCase(Prov St Lic #) (excluding DME)
UPIN

[24j Bottom] Rendering NPI

Select one of the following options:

Blank
Rendering NPI
Rendering NPI if provider belongs to a group, else blank

[25] Federal tax ID number

Select one of the following options:

Blank
Prov ID
Tax ID
UCase(Tax ID)

[25] Federal tax ID number type

Select one of the following options:

Blank
EIN
Read from claim (standard)
SSN

[27] Accept Assignment/Worker's Comp

Select one of the following options to indicate how to select the Accept Assignment box (Box 27):

Blank – select nothing
No – select No
Use Legacy Options – use previous settings
Yes – select Yes

[29] Amount Paid - Include adjustments for payers?

Select this option to display adjustments for payers on the CMS 1500 claim.

[29] Amount Paid - Include refunds for payers?

Select this option to include refunds in payer amount.

[29] Amount Paid - When zero dollar amount, display:

Select one of the following options:

0.00
Blank

[29] Amount Paid - Format

Select one of the following options:

999,999.99
999999.99

[30] Balance Due - When zero dollar amount, display:

Select one of the following options:

0.00
Blank

[30] Balance Due - Format

Select one of the following options:

999,999.99
999999.99

[30] Balance Due - Include Adjustments

Select one of the following options:

Ignore Adjustments
Include Adjustments of All Payers
Include Adjustments of Current Payer
Include Adjustments of Prior and Current Payer
Include Adjustments of Prior Payer

Use Box 29 setting

[30] Balance Due - Include Refunds

Select one of the following options:

<None>
Ignore Refunds
Include Refunds for All Payers
Use Box 29 setting

[29 & 30] Amount Paid & Balance Due - Total Location

Select one of the following options to indicate where to print the total amount paid for multi-page claims:

Grand total on first page only; blank on other pages
Grand total on last page only; 'page X of Y' on other pages
Grand total on last page only; blank on other pages
Total each page separately; no grand total

[31-1] Signature of physician or supplier

This claim printing option must have an option selected from the drop-down list. The option that is selected prints on the CMS 1500 box 31. The options available include:

‘Agreement on File’
'COMPUTER-GENERATED MM/DD/YY'
‘signature on file’
‘SIGNATURE ON FILE’ (upper case)
Blank
Current Date (mm/dd/yy}
Current Date (mm/dd/yyyy)
Group Name
Name of facility/location
Original Date (mm/dd/yy)
Original Date (mm/dd/yyyy)
Physician License Number
Provider Individual Number
Rendering name (Display As)
RENDERING NAME (Display As - Upper Case)
Rendering name (Last, First MI)
Rendering name (Last, First MI - Upper Case)

[31-2] Signature of physician or supplier

This claim printing option must have an option selected from the drop-down list. The option that is selected prints on the CMS 1500 box 31. The options available include:

‘Agreement on File’
'COMPUTER-GENERATED MM/DD/YY'
‘signature on file’
‘SIGNATURE ON FILE’ (upper case)
Blank
Current Date (mm/dd/yy}
Current Date (mm/dd/yyyy)
Original Date (mm/dd/yy)
Original Date (mm/dd/yyyy)
Physician License Number
Provider Individual Number
Rendering name (Display As)
RENDERING NAME (Display As - Upper Case)
Rendering name (Last, First MI)
Rendering name (Last, First MI - Upper Case)

[31-3] Signature of physician or supplier

This claim printing option must have an option selected from the drop-down list. The option that is selected prints on the CMS 1500 box 31. The options available include:

‘Agreement on File’
'COMPUTER-GENERATED MM/DD/YY'
‘signature on file’
‘SIGNATURE ON FILE’ (upper case)
Blank
Current Date (mm/dd/yy - right justified}
Current Date (mm/dd/yyyy)
Original Date (mm/dd/yy)
Original Date (mm/dd/yyyy)
Physician License Number
Provider Individual Number
Rendering name (Display As)
RENDERING NAME (Display As - Upper Case)
Rendering name (Last, First MI)
Rendering name (Last, First MI - Upper Case)

[32] COB1 Recent Paid Date or Batch Nbr below box

Select one of the following options:

Batch Nbr
Blank
Recent Date
Recent Date & Batch Nbr

[32] Convert values to upper case

Select this option to force all values in box 32, lines 1-4, to appear in upper case on the CMS1500 claim.

[32-1] Name/Addr where services rendered

Select one of the following options:

'SAME' if phys addr = fac/loc addr; else Name of fac/loc
'SAME' if phys name/addr = fac/loc & POS is office/inpat hosp; else Name of fac/loc
"SAME' if phys name/addr = fac/loc name/addr; else Name of fac/loc
Blank
Blank if phys addr = fac/loc addr; else Name of fac/loc
Blank if phys name/addr = fac/loc name/addr; else Name of fac/loc
Blank if POS is office; else Name of fac/loc
Blank if POS is office; Facility Name if not blank; else Practice Name
Facility Name if not blank; else Practice Name
Name of facility/location

[32-2] Name/Addr where services rendered

Select one of the following options:

Addr1 Addr2 of facility/location
Blank
Blank if phys addr = fac/loc addr; else Addr1 Addr2 of fac/loc
Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Addr1 Addr2 of fac/loc
Blank if phys name/addr = fac/loc name/addr; else Addr1 Addr2 of fac/loc
Blank if POS is office; else Addr1 Addr2 of fac/loc

[32-3] Name/Addr where services rendered

Select one of the following options:

Blank
Blank if phys addr = fac/loc addr; else City State Zip of fac/loc
Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else City St Zip of fac/loc
Blank if phys name/addr = fac/loc name/addr; else City State Zip of fac/loc
Blank if POS is office; else City State Zip of fac/loc
City State Zip of facility/location

[32-a] NPI

Select one of the following options:

Blank
Blank if phys addr = fac/loc addr; else Fac NPI
Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Fac NPI
Blank if phys name/addr = fac/loc; else Fac NPI
Blank if POS is office; else Fac NPI
Facility NPI

[32-b] Facility ID

Select one of the following options:

Blank
Blank if phys addr = fac/loc addr; else Fac ID (if present), else Mammography Cert of loc
Blank if phys name/addr = fac/loc & POS is office/inpat hosp; else Fac ID, else Mam Cert
Blank if phys name/addr = fac/loc; else Fac ID (if present), else Mammography Cert of loc
Blank if POS is office; else Fac ID (if present), else Mammography Cert of loc
Facility ID (if present), else Mammography Cert of location
Facility Taxonomy

[32-b & 33-b] Add space between qualifier and data

Select this option to add a space between the qualifier and the data for boxes 32-b and 33-b.

[33] Display group phone #

Select this option to print the group phone number of the billing provider in the top right corner of box 33.

[33-1] Physician's/Supplier's information

Select one of the following options:

Group Name
UCase(Group Name)
Group Phone
SAME
Supervising Name if supervising exists and is not blank; else Rendering Name
Supervising Phone if supervising exists and is not blank; else Rendering Phone

[33-2] Physician's/Supplier's information

Select one of the following options:

Group Addr1 & Addr2
UCase(Group Addr1 & Addr2)
UCase(Group Name)
Blank
Supervising Addr1 & Addr2 if supervising exists and is not blank; else Rendering Addr1 & Addr2
Supervising Name if supervising exists and is not blank; else Rendering Name

[33-3] Physician's/Supplier's information

Select one of the following options:

Group City & St & Zip
UCase(Group City & St & Zip)
UCase(Group Addr1 & Addr2)
Blank
Supervising City & St & Zip if supervising exists and is not blank; else Rendering City & St & Zip
Supervising Addr1 & Addr2 if supervising exists and is not blank; else Rendering Addr1 & Addr2

[33-4] Physician's/Supplier's information

Select one of the following options:

Blank
UCase(Group City & St & Zip)
Group Phone
Supervising City & St & Zip if supervising exists and is not blank; else Rendering City & St & Zip
Supervising Phone if supervising exists and is not blank; else Rendering Phone

[33-a] Display NPI

Select one of the following options:

Blank
NPI (group NPI if group billing, else provider individual NPI if billing as an individual)

[33-b Enable group logic] If Group # or Prov ID is selected in Box 33-b BELOW, display Group # only if the provider belongs to a group (Group # selected) or Prov ID if the provider does not belong to a group (Prov ID selected). If the provider is in a group and Prov ID is selected, display nothing.

Select this option to activate the following logic:

If Group # or Prov ID is selected in box 33 b BELOW, display Group # only if the provider belongs to a group (Group # selected) or Prov ID if the provider does not belong to a group (Prov ID selected). If the provider is in a group and Prov ID is selected, display nothing. If the provider is not in a group and Group # is selected, display nothing.

[33-b] Physician's/Supplier's information

Select one of the following options:

Group #
Prov ID & OptClaimValue1
Blank
OptClaimValue1
OptClaimValue2
Prov ID & OptClaimValue2
Group Opt Val
Prov Taxonomy code
Group Taxonomy code
Phys Billing Taxonomy code
State License Nbr
UCase(Group #)
Trim(Group #)
UCase(Trim(Group #)
Prov ID
Trim(Prov ID)
UCase(Trim(Prov ID)
Prov ID & Prov Tax ID
Prov ID & Group #

CMS 1500 (2005) Options

Recommendations

CMS 1500 (2012) Form Print Options for All Payers

UB(92) Options

CMS 1500 (2005) Options

CMS 1500 (2012) Form Print Options for All Payers

1500 CMS Options (2012)

1500 CMS Options (2012)

CMS 1500 (2012) Form Print Options for All Payers

UB(92) Options

CMS 1500 (2005) Options

CMS 1500 (2012) Form Print Options for All Payers

1500 CMS Options (2012)

1500 CMS Options (2012)