CMS1500 Synergy Flashcards
(48 cards)
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)
