CMS1500 Synergy Flashcards
1a
(The information from CMS1500 auto populates from our Software on to Office Ally/ Clearinghouse)
Insured’s ID
top right.
Line 2
Name
Line 3
DOB
Line 4
Insured’s Name
On Office Ally just click on the little blue line to duplicate.
Line 5 and Line 7 are same
(address)
Patient’s address
(zip code + Four Digits w/out dashes)
Line 7 Insured’s address
Line 6
Relationship?
self
Line 7
Insured’s address
*same check Office Ally to see it has the blue highlighted area to duplicate.
Line 8
Reserved for NUCC only
9 abcd
Other Insured’s name
(usually stays blank)
10 abc
Condition related to?
a. employment
b. auto
c. other
Line 11
(usually blank)
except for
11 a it’s DOB
- INSURED’S POLICY GROUP OR FECA NUMBER
FECA - Federal Employees Compensation Act. Is a 9 digit alphnumeric id (work-related conditions)
Line 11
a, b, c, d
- Group or FECA
a. DOB
b. Other (usually blank)
c. Ins Plan (usually blank)
d. Is there another HP?
Y or N
Line 12
Signautre
Line 13
SOF
Signature On File
Line 14
Date of IIP
Injury Illness Pregnancy (LMP)
Line 15
Other Date
This requires a Qual
Qual is a Qualifier
such as:
304 last seen
439 accident
454 Initial Treatment
Line 16
DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
Line 17
NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a
blank
it’s a little gray box above 17b
17b
NPI
(this is the referring provider’s NPI)
18
HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
LIne 19
ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
20
OUTSIDE LAB? $ CHARGES
- A-L
ICD Ind. is 9 for ICD9
or 0 for ICD10
21 is WHY (ICD)
24 is WHAT (CPT)
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)
Line 22
Resumission Code / Orig Ref NO.
(I see a 1 on the Resummision Code line
is it always 1? and Orig Ref NO. is blank.
Line 23
PRIOR AUTHORIZATION NUMBER
line 24a
Dates of service
*it has a range
*it also has 6 lines
24b
Place of Service
31 Skilled (part A)
33 Custodial (part B)
12 Home
24c
EMG
*it mans Emergency, but it’s usually blank for this type of service.
24 d & e
CPT Modifer Dx Pointer
73030- 26 RT - A
CPT/HCPCS MODIFIER
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
24e
The Dx Pointer line
is usd to indicate the appropriate order of importance in relation to the serivce being performed.
24f
charges
24g
Days or Units
(in this case it’s 1)
24 h
EPSDT (for children under 21)
EPSDT =
Early and Periodic Screening, Diagnostic and Treatment.
EPSDT
Family
Plan
24 i
NP (the NPI number goes on the next line 24J)
i
ID.
QUAL.
24J
RENDERING PROVIDER ID #
25
Federal Tax Id
SSN (x)EIN
26
Patient’s Account Number
(this is our claim number)
27
Accept Assignment
(x) Yes
28
Total Charge
29 blank
Amount Paid
(blank)
30 blank
Rsvd for NUCC Use
31
SOF
Signature on File
SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
32 a & b
they are blank
32
a (blank) NPI
b (blank)
SERVICE FACILITY LOCATION INFORMATION
example:3
Ridgeview - ALF
9825 Glen Center Drive
San Diego, CA 921311689
33
33a NPI
BILLING PROVIDER INFO & PH #
example:
323-559-9683
ALERRA LLC
32244 Paseo Adelanto #B
SAN JUAN CAPISTRANO, CA 926753
