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CMS 1500 New (02/12) Crosswalk

Header - Payer Name
- Payer Name
Block 1
- Insurance Type
Block 1a
- Insured's I.D. Number
Block 2
- Patient's Name
Block 3
- Patient's Birth Date
Block 4
- Insured's Name
Block 5
- Patient's Address
Block 6
- Patient Relation to Insured
Block 7
- Insured's Address
Block 8
- Reserved for NUCC Use
Block 9
- Other Insured's Name
Block 9a
- Other Insured's Policy or Group Number
Block 9b
- Reserved for NUCC Use
Block 9c
- Reserved for NUCC Use
Block 9d
- Insurance Plan Name or Program Name
Block 10a
- Patient Condition Related To: Employment
Block 10b
- Patient Condition Related To: Auto Accident
Block 10c
- Patient Condition Related To: Other Accident
Block 10d
- Claim Codes
Block 11
- Insured's Policy Group or FECA Number
Block 11a
- Insured's Date of Birth and Gender
Block 11b
- Other Claim ID
Block 11c
- Insurance Plan Name or Program Name
Block 11d
- Another Health Benefit Plan
Block 12
- Patient Signature
Block 13
- Insured Signature
Block 14
- Date of Current: (Illness, Injury or Pregnancy)
Block 15
- Same or Similar Illness
Block 16
- Dates Patient Unable to Work
Block 17
- Adding a Referring Provider
- Indicating Referring Provider on the claim
Block 17a
- Adding a Referring Provider Secondary/Legacy ID
- Indicating the Referring ProviderSecondary/Legacy ID on the claim
Block 17b
- Adding a Referring Provider NPI
- Indicating the Referring Provider NPI on the claim
Block 18
- Hospitalization Dates
Block 19
- Reserved for Local Use
Block 20
- Outside Lab
Block 21
- Diagnosis Codes
Block 22
- Resubmission Code and Original Reference Number
Block 23
- Prior Authorization Number
Block 24A
- Dates of Service
Block 24B
- Place of Service
Block 24C
- EMG
Block 24D
- CPT/HCPCS
- Modifiers
Block 24E
- Diagnosis Pointer
Block 24F
- Charges
Block 24G
- Days or Units
Block 24H
- EPSDT/Family Plan
Block 24I
- ID Qualifier (for Rendering Provider)
Block 24J
- Rendering Provider ID
- Rendering Provider NPI
Block 25
- Federal Tax I.D. Number
Block 26
- Patient Account Number
Block 27
- Accept Assignment
Block 28
- Total Charge
Block 29
- Amount Paid
Block 30
- Rsvd for NUCC Use
Block 31
- Signature of Physician
Block 32
- Service Facility Location Information
Block 32a
- Service Facility NPI
Block 32b
- Service Facility Legacy I.D.
Block 33
- Billing Provider Address and Phone
Block 33a
- Billing Provider NPI
Block 33b
- Billing Provider Legacy I.D.

Chapter & Lesson Total

Header - Payer Name 1
- Payer Name
Block 1 1
- Insurance Type
Block 1a 1
- Insured's I.D. Number
Block 2 1
- Patient's Name
Block 3 1
- Patient's Birth Date
Block 4 1
- Insured's Name
Block 5 1
- Patient's Address
Block 6 1
- Patient Relation to Insured
Block 7 1
- Insured's Address
Block 8 1
- Reserved for NUCC Use
Block 9 1
- Other Insured's Name
Block 9a 1
- Other Insured's Policy or Group Number
Block 9b 1
- Reserved for NUCC Use
Block 9c 1
- Reserved for NUCC Use
Block 9d 1
- Insurance Plan Name or Program Name
Block 10a 1
- Patient Condition Related To: Employment
Block 10b 1
- Patient Condition Related To: Auto Accident
Block 10c 1
- Patient Condition Related To: Other Accident
Block 10d 1
- Claim Codes
Block 11 1
- Insured's Policy Group or FECA Number
Block 11a 1
- Insured's Date of Birth and Gender
Block 11b 1
- Other Claim ID
Block 11c 1
- Insurance Plan Name or Program Name
Block 11d 1
- Another Health Benefit Plan
Block 12 1
- Patient Signature
Block 13 1
- Insured Signature
Block 14 1
- Date of Current: (Illness, Injury or Pregnancy)
Block 15 1
- Same or Similar Illness
Block 16 1
- Dates Patient Unable to Work
Block 17 2
- Adding a Referring Provider
- Indicating Referring Provider on the claim
Block 17a 2
- Adding a Referring Provider Secondary/Legacy ID
- Indicating the Referring ProviderSecondary/Legacy ID on the claim
Block 17b 2
- Adding a Referring Provider NPI
- Indicating the Referring Provider NPI on the claim
Block 18 1
- Hospitalization Dates
Block 19 1
- Reserved for Local Use
Block 20 1
- Outside Lab
Block 21 1
- Diagnosis Codes
Block 22 1
- Resubmission Code and Original Reference Number
Block 23 1
- Prior Authorization Number
Block 24A 1
- Dates of Service
Block 24B 1
- Place of Service
Block 24C 1
- EMG
Block 24D 2
- CPT/HCPCS
- Modifiers
Block 24E 1
- Diagnosis Pointer
Block 24F 1
- Charges
Block 24G 1
- Days or Units
Block 24H 1
- EPSDT/Family Plan
Block 24I 1
- ID Qualifier (for Rendering Provider)
Block 24J 2
- Rendering Provider ID
- Rendering Provider NPI
Block 25 1
- Federal Tax I.D. Number
Block 26 1
- Patient Account Number
Block 27 1
- Accept Assignment
Block 28 1
- Total Charge
Block 29 1
- Amount Paid
Block 30 1
- Rsvd for NUCC Use
Block 31 1
- Signature of Physician
Block 32 1
- Service Facility Location Information
Block 32a 1
- Service Facility NPI
Block 32b 1
- Service Facility Legacy I.D.
Block 33 1
- Billing Provider Address and Phone
Block 33a 1
- Billing Provider NPI
Block 33b 1
- Billing Provider Legacy I.D.

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*Disclaimer: SOAPware, Inc. cannot guarantee the completeness or accuracy of the information presented herein. Independent research and verification of all information is necessary to ensure compliance with all Meaningful Use, MACRA/MIPS, and CQM/PQRS requirements.

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