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CMS1500 Claim Form Guide (TheraNest)


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  • Updated

This guide explains how the fields in TheraNest populate the CMS 1500 claim form.   

 

Jump to Box  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33

 

Carrier Block

Carrier block is filled with Insurance Organization's name and address from Insurer Details page.

  • Billing > Insurers > Edit InsurerTN_0_.png

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Box 1

Current Insurer's Insurance Type from Insurer Details page.

  • Billing > Insurers > Edit Insurer
    TN_1.png

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Box 1a

Insured’s ID Number from Client's Bill To & Insurance Info page.

  • Open appropriate Client > Bill To & Insurance Info Tab
    TN_1a.png

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Box 2

Client's Name in format: Last Name, First Name, Middle Initial, e.g. "Doe, John, F"

  • Open appropriate Client > Details Tab
    TN_2.png

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Box 3

Client's DOB and Gender from Client Details page.

  • Open appropriate Client > Details Tab > Scroll to Manage Demographic Info Section
    TN_3.png

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Box 4

Insured's name in format: Last Name, First Name, Middle Initial, e.g. "Doe, John, F".

  • Relationship to the Insured is "Self", then the data is taken from the Client Details page.
    Open appropriate Client > Details Tab
    TN_4.1.png

  • OR, if not "Self", then data is taken from the Info About Insured section.
    Open appropriate Client > Bill To & Insurance Info Tab > Edit Insurer > Insured Information.
    TN_4.png

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Box 5

Box 5 contains the Client Address and Telephone Number.

  • Client's Address
    Open appropriate Client > Details Tab > Client Address

  • Client's Telephone 
    • TheraNest will use Phone Number is listed on the Bill To & Insurance Info tab. If no number is listed here, TheraNest will use then use the Mobile or Home Phone Number from the Client Details tab.
      TN_5.png

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Box 6

Relationship to Insured from Bill To & Insurance Info page.

  • Open appropriate Client > Bill To & Insurance Info Tab > Edit Insurance
    TN_6.png

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Box 7

Insured's address from Bill To & Insurance Info page.

  • Relationship to the Insured is "Self", then the data is taken from the Client Details page.
    Open appropriate Client > Details Tab
    TN_7.1.png

  • If not "Self", then data is taken from the Info About Insured section.
    Open appropriate Client > Bill To & Insurance Info Tab > Edit Insurer > Insured Information.
    TN_7.2.png

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Box 8

Is not filled in TheraNest.

 

Box 9

Box 9 indicates that there may be another Client Insurance listed that may cover the Client. If Box 11d is marked Yes, information will be listed here.

Other Insured Name (9), Other Insured Policy or Group Number (9a), and Insurance Plan Name or Program Name (9d) are filled from the Client's Insurance information.

NOTE: If the Secondary Insurance is used for CMS1500 is typed as Medicare, then this box is left blank. 

 

Open appropriate Client > Bill To & Insurance Info Tab > Edit Secondary Insurer

  • Insured Name (Box 9) comes from Insured information of Bill To & Insurance Info tab.
  • Other Insured Policy or Group Number (9a) comes from the Policy or FECA Number if listed. If not listed, this value is take from the Group Number field on the Bill To & Insurance Info tab.
  • Box 9b and 9c are not filled by TheraNest.
  • Insurance Plan Name or Program Name (9d) is taken from Plan Name field on Bill To & Insurance Info tab.TN_9.png

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Box 10

This is filled based on the answer listed within the Client Insurance details for the question Is Client's Condition related to an Accident?

Open appropriate Client > Bill To & Insurance Info Tab > Edit Insurer 

  • If Employment , Auto Accident, or Other Accident is selected, you will be prompted to enter more information. This information is used to populate boxes 10a-10c.
  • If NO is selected, then No will be marked for boxes 10a-10c. 
  • Box 10d is not filled by TheraNest.
    TN_10.png

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Box 11

Box 11 information comes from the Insurer you selected to submit to. Typically this will be the Primary Insurance unless you selected to bill the Secondary Insurance. 

NOTE: If selected insurance is secondary and it's type is Medicare, then these values are taken from Primary Insurance.

  • Policy or FECA Number (box 11) - or Group Number if Policy/FECA Number field is empty.
    Open appropriate Client > Bill To & Insurance Info Tab > Edit Insurer
  • Insured Person's DOB (11a)
    • IF, Relationship to the Insured is "Self", then the data is taken from the Client Details page.
      Open appropriate Client > Details Tab
    • IF, Relationship to the Insured is NOT "Self", then data is taken from Info About Insured section.
      Open appropriate Client > Bill To & Insurance Info Tab > Edit Insurer > Insured Information.
  • Box 11b is not filled by TheraNest.
  • Insurance Plan Name (11c) comes from Client's Insurance Details section.
    Open appropriate Client > Bill To & Insurance Info Tab > Edit Insurer
    TN_11.png

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Box 12

If Client Authorized Release of Information Necessary to Process Claims is marked as YES then box 12 will enter SIGNATURE ON FILE. Date is the date the form was created. 

NOTE: If marked Not Required, this field box 12 will be empty. 

  • Open appropriate Client > Bill To & Insurance Info Tab > Edit InsurerTN_12.png

 

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Box 13

If Authorize Payment to Provider is marked YES, then box 13 will enter SIGNATURE ON FILE. 

NOTE: If marked Not Required, this field box 12 will be empty. 

  • Open appropriate Client > Bill To & Insurance Info Tab > Edit InsurerTN_17.pngTN_13.png

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Box 14, 15, 16

Is not filled by TheraNest.

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Box 17

Box 17 is populated from Referrer section on the Bill To & Insurance Info tab.

Open appropriate Client > Bill To & Insurance Info Tab 

  • Box 17 - The Referring Provider Name must be entered on Bill To & Insurance Info tab. 
  • Box 17 - Qualifier:
    • DN displays if Referrer Name has value, otherwise it's empty (both Name and Qualifier depend on Referrer NPI).
    • DQ displays when Use Supervising Provider on Claims is marked YES. You can only toggle YES when the Referring Provider's full Name and NPI is populated.
  • Box 17a is not filled by TheraNest
  • Box 17b is Referrer's NPI.
    TN_17.png

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Box 18, 19, 20

Is not filled by TheraNest.

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Box 21

Diagnoses’ for Services billed. Diagnosis Codes are taken from Initial Assessment of Cases that contain Progress Notes related to Services billed. 

Codes Legend:

  • ICD Version: ICD-9 = 9
    NOTE: ICD-9 is used only for Services performed before October 1, 2015.
  • ICD 10 = 0

Open appropriate Client > Notes > Cases > Progress Note for desired Service Date

TN_21.png

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Box 22

Box 22 populates when Ask for resubmission details prior to Re-Submit failed Claim is selected in the Insurers EDI File Settings.

Billing tab > Insurers > Edit Insurer

TN_22a.png

When Resubmitting the Claim from the Submitted Claims page, enter the required Resubmission details:

  • Original Reference Number aka the Payer Number - You may need to call the Payer to get this information. 
    TN_22.png

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Box 23

Prior Authorization Number from Bill To & Insurance Info page.

  • Open appropriate Client > Bill To & Insurance Info Tab > Edit Insurer
    TN_23.png

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Box 24

Billed services.

TN_24.0.png

 

Column A - Date(s) of Service

Date of Service is taken from Start and End Date and Time for Appointment. Found on Invoice.

TN_24a.png

 

Column B - Place of Service

Place of Service is pulled from the Invoice. The dropdown suggests standard values, the default value is Office (code 11).

TN_24b.png

Column C is not filled in TheraNest

 

Column D - Procedures, Services, or Supplies 

This is listed on the Invoice, but the information the Invoice pulls from is list the Service Type details.

  • Organization > Service Types > Edit Service TypeTN_24d.png

Column E - Diagnosis Pointer

The Diagnosis Pointer is the Letter field of the Diagnosis in Box 21.

TN_24e.png

 

Column F - Charges

Amount Billed for Services pulled from the Invoice.

TN_24f.png

 

Column G - Days or Units

This is pulled in from the Invoice.

TN_24g.png

 

Column H is not filled in TheraNest

 

Column I - ID Qualifier of Additional Insurer ID

Valid additional IDs for box 24I must meet the following conditions. Valid qualifier values are:

  • 0B State License Number
  • 1G Provider UPIN Number
  • G2 Provider Commercial Number
  • LU Location Number
  • ZZ Provider Taxonomy.

Column J - Rendering Provider ID #s

  • Top Line - Is populated with ID Number of Insurer's Additional ID from box 24I.
  •  Bottom Line - Is populated with Rendering Provider NPI of the "Staff Member" on the invoice.
    24d.png

    • If PQRS is used, PQRS measures are also put into box 24 after the corresponding service.
    •  QDC codes are placed in column D, diagnosis pointer points to one of diagnoses of parent service.
    •  Charged sum is $0.01.

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Box 25

Depends on Billing Provider specified in the invoice.
 If the "Bill with selected staff NPI?" box is checked, the Tax ID of selected Provider is used.
 Otherwise, Tax ID of the Organization is used.

25.png

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Box 26

Client ID Number on the Client Details page.

26.png

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Box 27

Value of Accept Assignment flag on Bill To & Insurance Info page.

27.png

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Box 28

Sum of charges for all services.

28.png

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Box 29

Sum of payments on the invoice.

29.png

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Box 30

Is not filled by TheraNest.

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Box 31

Rendering Provider associated with the invoice.

  • If no staff is associated with an invoice, then "SIGNATURE ON FILE" is printed.

Date of form creation.

Snag_42b12e.png

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Box 32

Contains several lines:

Line 1 – Facility Name, i.e. Organization's legal name.

Line 2 - Location Address: Number, Street, Suite.
Line 3 - Location Address: City, State, Zip.
If the invoice's service item has an associated appointment, the Location is pulled from the appointment. Otherwise, it's pulled from the Client Details page.
 
 Box 32.a is facility NPI of Location. If it's not specified, then Facility NPI of the organization is used.32.png

 

Box 32.b. is not filled by TheraNest.

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Box 33

The box content depends on Billing Provider and Provider's location that are specified on the invoice page:

33.png

1) Billing provider address values and Phone Number are taken from "Send Payments To (if different from Location)" section, and if it's empty (i.e. all fields of the section are empty), then values from "Location Address" section are used.

33a.png

2) Billing Provider Name: if "Bill with selected staff NPI?" box is checked and Provider is selected, then this Provider's name is used.
 Otherwise Organization's legal name is used.

33b.png


 
 Box 33.a.

Contains Billing Provider's NPI. Otherwise, organization's NPI is used.

33c.png

Box 33.b.

The field is constructed from the qualifier and ID Number of first valid Additional ID of current Insurer.

33d.png

The allowed qualifiers for box 33.b are:

  • 0B State License Number
  • G2 Provider Commercial Number (currently only prints on the physical CMS-1500. It is not sent in the electronic file)
  • ZZ Provider Taxonomy

If  Provider is a used:
 The first additional id is taken that matches the following conditions:

  • its qualifier belongs to allowed qualifiers.
  • its location is "Any" or matches the Provider's location specified in the invoice
  • "Related To" field is "Organization & Any Staff" or Billing Provider's name.

If Provider is Organization:

The first additional id is taken that matches the following conditions:

  • Its qualifier belongs to allowed qualifiers.
  •  Its location is "Any" or matches the Provider's location specified in the invoice.
  •  "Related To" field is "Organization & Any Staff" or "Organization".

You can print/download the step-by-step instructions via PDF here: CMS-1500-Billing-Manual.pdf

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