Introduction

PureEHR will pull data from a patient’s chart to populate the CMS 1500 form. The following is a guide identifying which fields the data will be pulled from. 

Basic Essential Information

You can generate CMS 1500 for an individual appointment, by clicking on the appointment and then going to the Billing tab. Now to view the form, click on the View CMS 1500 form button in the top right corner. 

The CMS 1500 form will be updated automatically based on the Visit Profile. 

The system will pull data from the Insurance tab(Primary Information > Insurance). 

CMS 1500 Items

Box 1 - Healthcare Program (Primary Information > Insurance)

Box 1a - Insurance Company ID Number(Primary Information > Insurance)

Box 2 - Data is pulled from First Name, Last Name, and Middle Name found under Patient Information. 

Box 3 - Data is pulled from the Patient DOB and Gender under Demographics. (Primary Information > Demographics)

Box 4 - In the below-given figure, there is a checkbox called Subscriber is the Patient. If it is selected, Box 4 remains empty. But if it is de-selected, Subscriber fields will appear below the Insurance card rear field, which will allow you to enter the subscriber information when the patient is covered in someone else’s insurance policy. 

Box 5 - Address information is found under the demographics tab. 

PATIENT’S ADDRESS: Address (Demographics)

CITY: City (Demographics)

STATE: State (Demographics)

ZIPCODE: Zipcode (Demographics)

TELEPHONE: Cell phone (Primary Information)

Box 6 - Pulls the information from the Patients relationship to the subscriber. 

Box 7 - Pulls the address information of the Subscriber’s address. (Patient Information > Insurance)

INSURED’S ADDRESS: Subscriber Address

CITY: Subscriber City 

STATE: Subscriber State

ZIPCODE: Subscriber zipcode

TELEPHONE: Subscriber phone

Box 8 - This box is reserved for NUCC use

Box 9 - This box will display the information on Secondary Insurance if a subscriber’s information is present. This field pulls the information of secondary insurance Subscriber Last Name, Subscriber First Name, Subscriber Middle Name. (Patient Information > Insurance > Secondary)

Box 9a - Pulls the information from the field Secondary Insurance Group Number/ FECA Number. (Patient Information > Insurance > Secondary)

Box 9b - This field is reserved for NUCC use.

Box 9c - This field is reserved for NUCC use.

Box 9d - Pulls Information from the field Secondary Insurance Group Name. (Patient Information > Insurance > Secondary)

Box 10 - Pulls the information from Employment, Auto Accident (State), Other Accident. 

The state field will be seen if one selects yes in an auto accident. (Edit Appointment > Billing)

Box 11 - This information is for Primary Insurance. This information is pulled from the field Insurance Group Number/ FECA Number under the Insurance tab. (Patient Information > Insurance > Primary)

Box 11a - This information is for Primary Insurance. This information is pulled from the field Subscriber DOB. (Patient Information > Insurance > Primary)

Box 11b - This is reserved for NUCC.

Box 11c -  This information is for Primary Insurance. This information is pulled from the field Insurance Plan Name. (Patient Information > Insurance > Primary)

Box 11d - If the Primary Insurance is being used and there is data under Secondary Insurance, this box will be marked as Yes. If marked as yes then fill in Box 9, 9a, 9d. 

Box 12 - This field is hard coded as Signature on File and currents date. 

Box 13 - This field is hard coded as Signature on File.

Box 14 - Pulls information from the field Onset Date Type and Onset Date. (Edit Appointment > Billing)

Box 15 - Pulls information from the field Other Date Type and Other Date. (edit appointment > Billing)

Box 16 - Pulls information from Patient was unable to work from and Patient was unable to work to as shown below. 

Box 17 - Pulls information from the field called Referring Provider ID. Identifier DN will be applied to referring provider. If no information is found from the referring provider field then the information in the field of Ordering Provider ID is considered. Identifier DK will be applied to the ordering provider. (Patient Information > Demographics)

Box 17a - By default, this box will not populate with data.

Box 17b - Pulls the information from the field Referring Dr. NPI Number. If data of referring dr is not available, then by default the information of the Ordering dr will be considered. 

Box 18 - Data should be entered in the field of patient hospitalization related to the current services. 

Box 19 - Pulls data from the field Ambulance Service Codes. (Edit appointment > Billing)

Box 20 - Pulls the information from the field Outside Lab Entity Name and Outside Lab Charges. (Edit Appointment > Billing)

Box 21 - All the ICD codes applied to the appointment will be displayed here. Up to 12 ICD codes can be entered here.

Box 22 - Pulls information from Claim Ref. Number as shown below (Claim Ref. Number is seen after Billing status is selected as Bill Insurance, Insurance Type as Primary, Payment Profile as Insurance, Claim Type as Resubmit). 

Box 23 - Pulls the information from Prior Authorization Number as shown below.  

Box 24 - Pulls the information of the procedure codes displayed with the appointments. 

Box 24a - Displays the date of service associated with an individual CPT code. By default, the To and From date will pull the information from the date of the appointment. 

Box 24b - Pulls the information from the field Place of Service. (Office Management > Edit Office > Office Billing)

Box 24c - Pulls the information from the field Emergency Service. (Edit appointment > Billing)

Box 24d - Will display the CPT/ HCPCS codes and corresponding modifiers attached to an appointment. (Edit appointment > Billing)

Box 24e - This box will display Diagnosis Pointers entered for any code. These pointers link to the diagnosis codes entered in box 21. (Edit appointment > Billing)

Box 24f - Pulls the information from the field Price. Price will be multiplied by Quantity. (Edit appointment > Billing)

Box 24g - Pulls the information from the field Quantity. (Edit appointment > Billing)

Box 24h - Pulls information from the field EPSDT Services. (Patient Information > Demographics)

Box 24i - This field will remain static with the NPI Identifier.

Box 24j - This field will display the information of the rendering provider NPI appointed to an appointment. (Provider management > Provider > Identifiers)

Box 25 - Pulls the information from the field Federal Tax Type. When the SSN is selected, you will be allowed to enter the SSN Number; if EIN is selected, you will be allowed to enter the EIN Number. (Provider management > edit provider > Billing)

Box 26 - This field is autogenerated by the PureEHR software. 

Box 27 - This field is autogenerated as Yes

Box 28 - This box will calculate the total charges in box 24f.

Box 30 - This field is reserved for NUCC use.

Box 31 - Pulls data from the field First Name and Last Name. (Provider Management > Provider)

The date displayed will be the date that the CMS 1500 form was generated.

Box 32 - pulls the information from Office Name, Address, City, State, Zip Code(Office management > Offices), Facility NPI(Office management > Office Billing)

Box 32a - By default, it will display the data in the field from Rendering Provider NPI. 

Box 32b - By default, this box will not populate with data.

Box 33 - Pulls information from Billing address (Settings > Provider Management > Edit > Provider Billing). Check the Is Billing Enable checkbox as shown below. 

Box 33a - Pulls information from Billing NPI(Individual Provider NPI) as shown below. 

Box 33b -  By default, this box will not populate with data.