CMS 1500 (2012)

Field	CMS 1500 (2012) Options Description Exceptions: When Payer is Secondary Tab
[1] Insured's program	Select one of the following options: <none> Blank Use Legacy Standards Current Program with X Current Program with P Other if Medicare is Primary If Medicaid is secondary to Medicare, check both Medicare and Medicaid Check Medicare when Secondary payer is Medicaid else Payer Claim Type
[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 Primary insured's policy number Secondary payer's policy # + Plan Code Primary 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 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) 'SAME' if patient and primary insured are same; else LastName FirstName MI of insured 'SAME' if patient and primary insured are same; else LastName FirstName MI of primary insured 'SAME' if primary insured and sec insured are same; else LastName FirstName MI of primary insured Blank Blank if patient and insured are same; else LastName FirstName MI of insured If patient = insured, Blank if Medicare 1st, else '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 Blank if primary is Medicare, else primary insured's name Insured's name if 3rd ins exists and not patient else SAME; if no 3rd ins blank Primary insured's name Use Legacy Standards
[9a] Other Insured's group number	Select one of the following options: <none> Blank Blank if primary is Medicare, else primary insured's id Current insured's policy number Primary insured's group number Primary payer's policy number TPL When Medicare is secondary, this setting prints the primary payer's TPL code. 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 Blank if primary is Medicare, else primary insured's DOB and Sex Primary insured's DOB and Sex 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 Addr2 of MG if MG is 1/3; else Pri Addr1 if MCD is 3; else Sup Addr1&2 if Sup is 1/3; else Pri Addr1 Addr1 Addr2 of primary payer if no tertiary payer; else Insured's Emp Name of tertiary Blank Insured's Emp Name of primary Insured's Emp Name of primary if primary insured diff from secondary insured; else Blank Insured's Emp Name of primary if primary is not Medicare; else Blank Primary Amt Paid if primary is Medicare; else Insured's Emp Name of primary UCase(Insured's Emp Name of primary) 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: '620' if primary is Medicare; else Name of primary payer Blank City State Zip of primary payer if no tertiary payer; else Name of tertiary payer MedigapID# of MG if MG is 2nd; else blank Name of MG if MG is 1st/3rd; else Name of Suppl if Suppl is 1st/3rd; else Addr2 of primary Name of primary payer Name of primary payer if primary insured diff from secondary insured; else Blank Name of primary payer if primary is not Medicare; else Blank Name of secondary payer Other insured's group number - TPL Code UCase(Name State City of primary payer) UCase(Name of primary 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 Primary payer plan code (prints the plan code from the payer master file) "3" (Prints a value of 3.) "8" (Prints a value of 8.) Other insured's group number - TPL Code Print "1" if Primary Amount Paid=0 and Secondary payer is Medicaid Attachment if Secondary Medicaid If EPSDT print 8 otherwise print 3 "1" if Primary is Medicare and Primary Amount Paid = 0 "2" if Primary is BCBS "6" if Primary is Central Certification, Other Fed. Program, or Self Pay "3" if Primary is Champus, Commercial, or Workers Comp Primary policy number "3" if Primary Amount Paid > 0; else "S" "$" + Primary Amount Paid if Primary Medicare ("$0" = Blank) Secondary policy number
[11] Insured's policy group or FECA number	Select one of the following options: Blank Blank if primary payer is Medicare; else Insured ID # from primary payer Group # from primary payer & Insured ID # from primary payer Group # from primary payer if primary paid amt > 0; else Blank Group # from secondary payer Insured ID # from primary payer Insured ID # from primary payer if not blank; else Group # from primary payer Insured ID # from secondary payer Insured ID # from secondary payer if not blank; else Group # from secondary payer NONE NONE if 2nd or 3rd is Medicaid or Medigap; else Insured ID # from primary payer NONE if Insur status is retired else Ins ID # from primary payer if not blank; else Group # from primary payer UCase(Group # from secondary 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)
[11a] Insured's date of birth	Select one of the following options: <none> Blank Primary insured's DOB Primary insured's DOB if secondary ins is Medicare Secondary Insured's DOB
[11a] Display insured's sex	Select one of the following options: Display insured's sex <none> Blank
[11 b] Other Claim ID	Select this option to print the"Y4" qualifier and the Property Casualty Claim Number in box 11b. Note: "Y4" prints only if Y4 is selected on the Master Files System > Payers > Select Payer or New > System Tab > Provider Payer Qualifiers box > 11 b Property Casualty Claim > Qualifier drop-down box. The Property Casualty Claim Number prints only if this number is entered on the Patient Chart window > Insurance Tab > Verification> Patient Insurance - Encounter window > Property / Casualty Number field.
[11c] Insurance plan name or program name	Select one of the following options: Blank Insured's ID # from secondary Primary MSP payer id; else primary payer name Primary payer name Primary payer name 'of' primary payer state if primary is BCBS; else primary payer name Primary payer name if insured is patient Primary payer Name if primary paid amt > 0 Primary payer name if primary payer is not Medicare Primary payer plan code Secondary payer name UCase (primary MSP payer id; else primary payer name) UCase(primary payer name) UCase(secondary payer name)
[11d] Is there another health plan?	Select one of the following options: Blank - Leave this field blank, if the primary plan is a commercial plan. No - The plan is not a commercial plan. Yes - The plan is a commercial plan.
[17a] Ref. Provider or Other Sources ID number	Select one of the following options: <none> NEIC/Payer Number (Data pulls from the Payer Defaults - 1 tab in the Payer master file).
[22] Medicaid Resubmission Code	Select one of the following options: <none> Claim Balance
[22] Original Ref No	Select one of the following options: Blank Prior Payer Ref # - Prints the Prior Payer Reference Number from the Claim Maintenance > Claim Detail window in box 22 Document Control Number. Resub Ref # - Pints the Resubmission Code from the Claim Maintenance > Claim Detail window if the claim is a replacement (7) or Void/Cancel of Prior claim (8). Prints the ICN in box 22 of the paper CMS 1500 (2005 and 2012) claim.
[24j Enable group logic] if Prov ID is selected in box 24j 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 activate the following logic: 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. Note: This is the top portion of the [24j] Rendering Provider ID # field.
[24j TOP] Reserved for local use	Select one of the following options: <none> Allow or Deduct Amt $$.==/$$== (excluding DME) For example: I f 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) Group Taxonomy 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 Note: This is the bottom portion of the [24j] Rendering Provider ID # field.
[29] Amount Paid	Select one of the following options: Blank Pat paid amt Pat paid amt if Pri is Commercial; else Blank Pri (if not Medicare) + Ter + Pat paid amt if encounter has non-Medicare/Medicaid payers; else Blank Pri (if not Medicare) + Ter paid amt Pri + Sec + Ter + Pat paid amt Pri + Sec + Ter paid amt Pri + Ter + Pat paid amt Pri + Ter + Pat paid amt if Pri not Medicare; else Blank Pri + Ter paid amt Pri + Ter paid amt if Pri not Medicaid; else Blank Pri + Ter paid amt if Pri not Medicare/Medicaid; else Blank Pri + Ter paid amt if Pri not Medicare; else Blank Pri + Ter paid amt if total paid amt > 0; else 1.00 Pri paid amt Pri paid amt if paid amt > 0; else 1.00 Pri paid amt if Pri is Medicare; else Blank Pri paid amt if Pri not Medicare/Medicaid; else Blank
[30] Balance Due	Select one of the following options: Blank Blank if primary payer is Commercial; else Box 28 minus Box 29 Blank if primary payer is Medicare; else Box 28 minus Box 29 Box 28 minus [primary (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 Box 28 minus Box 29 minus Box 10d if primary payer is Commercial; else Box 28 minus Box 29 Note: This is the Reserved for NUCC Use field on the claim form.

[1] Insured's program

Select one of the following options:

<none>
Blank
Use Legacy Standards
Current Program with X
Current Program with P
Other if Medicare is Primary
If Medicaid is secondary to Medicare, check both Medicare and Medicaid
Check Medicare when Secondary payer is Medicaid else Payer Claim Type

[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
Primary insured's policy number
Secondary payer's policy # + Plan Code
Primary 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 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)
'SAME' if patient and primary insured are same; else LastName FirstName MI of insured
'SAME' if patient and primary insured are same; else LastName FirstName MI of primary insured
'SAME' if primary insured and sec insured are same; else LastName FirstName MI of primary insured
Blank
Blank if patient and insured are same; else LastName FirstName MI of insured
If patient = insured, Blank if Medicare 1st, else '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
Blank if primary is Medicare, else primary insured's name
Insured's name if 3rd ins exists and not patient else SAME; if no 3rd ins blank
Primary insured's name
Use Legacy Standards

[9a] Other Insured's group number

Select one of the following options:

<none>
Blank
Blank if primary is Medicare, else primary insured's id
Current insured's policy number
Primary insured's group number
Primary payer's policy number
TPL
When Medicare is secondary, this setting prints the primary payer's TPL code.
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
Blank if primary is Medicare, else primary insured's DOB and Sex
Primary insured's DOB and Sex
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 Addr2 of MG if MG is 1/3; else Pri Addr1 if MCD is 3; else Sup Addr1&2 if Sup is 1/3; else Pri Addr1
Addr1 Addr2 of primary payer if no tertiary payer; else Insured's Emp Name of tertiary
Blank
Insured's Emp Name of primary
Insured's Emp Name of primary if primary insured diff from secondary insured; else Blank
Insured's Emp Name of primary if primary is not Medicare; else Blank
Primary Amt Paid if primary is Medicare; else Insured's Emp Name of primary
UCase(Insured's Emp Name of primary)

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:

'620' if primary is Medicare; else Name of primary payer
Blank
City State Zip of primary payer if no tertiary payer; else Name of tertiary payer
MedigapID# of MG if MG is 2nd; else blank
Name of MG if MG is 1st/3rd; else Name of Suppl if Suppl is 1st/3rd; else Addr2 of primary
Name of primary payer
Name of primary payer if primary insured diff from secondary insured; else Blank
Name of primary payer if primary is not Medicare; else Blank
Name of secondary payer
Other insured's group number - TPL Code
UCase(Name State City of primary payer)
UCase(Name of primary 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
Primary payer plan code (prints the plan code from the payer master file)
"3" (Prints a value of 3.)
"8" (Prints a value of 8.)
Other insured's group number - TPL Code
Print "1" if Primary Amount Paid=0 and Secondary payer is Medicaid
Attachment if Secondary Medicaid
If EPSDT print 8 otherwise print 3
"1" if Primary is Medicare and Primary Amount Paid = 0
"2" if Primary is BCBS
"6" if Primary is Central Certification, Other Fed. Program, or Self Pay
"3" if Primary is Champus, Commercial, or Workers Comp
Primary policy number
"3" if Primary Amount Paid > 0; else "S"
"$" + Primary Amount Paid if Primary Medicare ("$0" = Blank)
Secondary policy number

[11] Insured's policy group or FECA number

Select one of the following options:

Blank
Blank if primary payer is Medicare; else Insured ID # from primary payer
Group # from primary payer & Insured ID # from primary payer
Group # from primary payer if primary paid amt > 0; else Blank
Group # from secondary payer
Insured ID # from primary payer
Insured ID # from primary payer if not blank; else Group # from primary payer
Insured ID # from secondary payer
Insured ID # from secondary payer if not blank; else Group # from secondary payer
NONE
NONE if 2nd or 3rd is Medicaid or Medigap; else Insured ID # from primary payer
NONE if Insur status is retired else Ins ID # from primary payer if not blank; else Group # from primary payer
UCase(Group # from secondary 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)

[11a] Insured's date of birth

Select one of the following options:

<none>
Blank
Primary insured's DOB
Primary insured's DOB if secondary ins is Medicare
Secondary Insured's DOB

[11a] Display insured's sex

Select one of the following options:

Display insured's sex
<none>
Blank

[11 b] Other Claim ID

Select this option to print the"Y4" qualifier and the Property Casualty Claim Number in box 11b.

Note:

"Y4" prints only if Y4 is selected on the Master Files System > Payers > Select Payer or New > System Tab > Provider Payer Qualifiers box > 11 b Property Casualty Claim > Qualifier drop-down box.

The Property Casualty Claim Number prints only if this number is entered on the Patient Chart window > Insurance Tab > Verification> Patient Insurance - Encounter window > Property / Casualty Number field.

[11c] Insurance plan name or program name

Select one of the following options:

Blank
Insured's ID # from secondary
Primary MSP payer id; else primary payer name
Primary payer name
Primary payer name 'of' primary payer state if primary is BCBS; else primary payer name
Primary payer name if insured is patient
Primary payer Name if primary paid amt > 0
Primary payer name if primary payer is not Medicare
Primary payer plan code
Secondary payer name
UCase (primary MSP payer id; else primary payer name)
UCase(primary payer name)
UCase(secondary payer name)

[11d] Is there another health plan?

Select one of the following options:

Blank - Leave this field blank, if the primary plan is a commercial plan.
No - The plan is not a commercial plan.
Yes - The plan is a commercial plan.

[17a] Ref. Provider or Other Sources ID number

Select one of the following options:

<none>
NEIC/Payer Number (Data pulls from the Payer Defaults - 1 tab in the Payer master file).

[22] Medicaid Resubmission Code

Select one of the following options:

<none>
Claim Balance

[22] Original Ref No

Select one of the following options:

Blank
Prior Payer Ref # - Prints the Prior Payer Reference Number from the Claim Maintenance > Claim Detail window in box 22 Document Control Number.
Resub Ref # - Pints the Resubmission Code from the Claim Maintenance > Claim Detail window if the claim is a replacement (7) or Void/Cancel of Prior claim (8). Prints the ICN in box 22 of the paper CMS 1500 (2005 and 2012) claim.

[24j Enable group logic] if Prov ID is selected in box 24j 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 activate the following logic:

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.
Note: This is the top portion of the [24j] Rendering Provider ID # field.

[24j TOP] Reserved for local use

Select one of the following options:

<none>
Allow or Deduct Amt $$.==/$$== (excluding DME)
For example: I f 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)
Group Taxonomy
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
Note: This is the bottom portion of the [24j] Rendering Provider ID # field.

[29] Amount Paid

Select one of the following options:

Blank
Pat paid amt
Pat paid amt if Pri is Commercial; else Blank
Pri (if not Medicare) + Ter + Pat paid amt if encounter has non-Medicare/Medicaid payers; else Blank
Pri (if not Medicare) + Ter paid amt
Pri + Sec + Ter + Pat paid amt
Pri + Sec + Ter paid amt
Pri + Ter + Pat paid amt
Pri + Ter + Pat paid amt if Pri not Medicare; else Blank
Pri + Ter paid amt
Pri + Ter paid amt if Pri not Medicaid; else Blank
Pri + Ter paid amt if Pri not Medicare/Medicaid; else Blank
Pri + Ter paid amt if Pri not Medicare; else Blank
Pri + Ter paid amt if total paid amt > 0; else 1.00
Pri paid amt
Pri paid amt if paid amt > 0; else 1.00
Pri paid amt if Pri is Medicare; else Blank
Pri paid amt if Pri not Medicare/Medicaid; else Blank

[30] Balance Due

Select one of the following options:

Blank
Blank if primary payer is Commercial; else Box 28 minus Box 29
Blank if primary payer is Medicare; else Box 28 minus Box 29
Box 28 minus [primary (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
Box 28 minus Box 29 minus Box 10d if primary payer is Commercial; else Box 28 minus Box 29

Note: This is the Reserved for NUCC Use field on the claim form.

CMS 1500 (2012)

Recommendations

CMS 1500 (2012)

1500 CMS Options (2012)

1500 CMS Options (2012)

1500 CMS Options (2012)

1500 CMS Options (2012)

CMS 1500 (2005) Options

CMS 1500 (2012)

1500 CMS Options (2012)

1500 CMS Options (2012)

1500 CMS Options (2012)

1500 CMS Options (2012)

CMS 1500 (2005) Options