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
