How does PracticeQ Information Populate in the CMS-1500 Claim Form?

Wondering where your PracticeQ data appears on the CMS-1500 claim form? Use the guide below to see how each field maps.

Click a Claim Field from the list to see how it's mapped!

**Any fields not listed below are not supported by PracticeQ.

  • Field 1
  • Field 1a (Insured’s I.D. Number)
  • Field 2 (Patients Name)
  • Field 3 (Patient’s Birth Date/Sex)
  • Field 4 (Insured’s Name)
  • Field 5 (Patient’s Address)
  • Field 6 (Patient Relationship to Insured)
  • Field 7 (Insured’s Address)
  • Field 9 Boxes
  • Field 9a (Other Insured’s Policy or Group Number)
  • Field 9d (Insured’s Plan Name or Program Name)
  • Field 10a.b.c. (Is Patient Condition Related to)
  • Field 11 (Insured’s Policy Group or FECA Number)
  • Field 11a (Insured’s Date of Birth)
  • Field 11c (Insurance Plan Name or Program Name)
  • Field 11d (Is there another health benefit plan?)
  • Field 12 (Patient’s or Authorized Person’s Signature?)
  • Field 13 (Insured’s or Authorized Person’s Signature?)
  • Field 14 (Date of current Illness, Injury or Pregnancy)
  • Field 15 (Other Date)
  • Field 16 (Dates Patient Unable to Work in Current Occupation)
  • Field 17 (Name of Referring Provider)
  • Field 17a (Name of Referring Provider)
  • Field 17b (NPI)
  • Field 18 (Hospitalization Dates Related to Current Services)
  • Field 19 (Additional Claim Information)
  • Field 20 (Outside Lab)
  • Field 21 (Diagnosis or Nature of Illness or Injury)
  • Field 22 (Resubmission Code)
  • Field 23 (Prior Authorization Number)
  • Field 24A (Date(s) of Service)
  • Field 24B (Place of Service)
  • Field 24D (CPT/HCPCS)
  • Field 24D (Modifiers)
  • Field 24E (Diagnosis Pointer)
  • Field 24F (Charges)
  • Field 24G (Days or Units)
  • *Field 24H (EPSDT)
  • Field 24I (ID. QUAL.)
  • Field 24J (Rendering Provider ID#)
  • Field 25 (Federal Tax I.D.Number)
  • Field 26 (Patient’s Account Number)
  • Field 27 (Accept Assignment)
  • Field 28 (Total Charge)
  • Field 29 (Amount Paid)
  • Field 31 (Signature of Physician or Supplier)
  • Field 32 (Service Facility Location Information)
  • Field 32a (NPI)
  • Field 32b (Service Facility Location Information)
  • Field 33 (Billing Provider)
  • Field 33a (NPI)
  • Field 33b (Taxonomy)

    •

    Field 1

    • Lists → Claims → Claim Settings → Payers Tab → Payer → Payer Type


    Field 1a (Insured’s I.D. Number)

    • Lists → Clients → Client → Overview → Primary Insurance  → Member ID/Policy# field


    Field 2 (Patients Name)

    • Lists → Clients → Client → Overview → Basic Information → Name field, OR 
    • Lists → Clients → Client → Claims Tab → Claim Defaults Button → Patient Legal Name field


    Field 3 (Patient’s Birth Date/Sex) 

    • Lists → Clients → Client → Overview → Basic Information → Date of Birth field and Sex field


    Field 4 (Insured’s Name)

    • Lists → Clients → Client → Overview → Primary Insurance → Policyholder Information → Name field


    Field 5 (Patient’s Address) 

    • Lists → Clients → Client → Overview → Basic Information → Address field


    Field 6 (Patient Relationship to Insured) 

    • Lists → Clients → Client → Overview → Primary Insurance → Policyholder Information → Client Relationship field


    Field 7 (Insured’s Address) 

    • Lists → Clients → Client → Overview → Primary Insurance → Policyholder Information → Street Address field(s)


    Field 9 Boxes

    NOTE: The Field 9 boxes below will populate only if Include Secondary Insurance on Primary Claims is checked under the Secondary Insurance heading.

    Field 9 (Other Insured’s Name)

    • Lists → Clients → Client → Overview → Secondary Insurance → Policyholder Information → Name field 


    Field 9a (Other Insured’s Policy or Group Number)

    • Lists → Clients → Client → Overview → Secondary Insurance → Member ID field or Group Number field
    • If both the Member ID and the Group Number are present in the Client Overview, the Group Number will populate on the claim.


    Field 9d (Insured’s Plan Name or Program Name)

    • Lists → Clients → Client → Overview → Secondary Insurance → Plan/Program Name field 


    Field 10a.b.c. (Is Patient Condition Related to)

    Lists → Clients → Client → Claims → Claim Defaults → Patient condition related to: (Check Boxes)

    Field 11 (Insured’s Policy Group or FECA Number)

    • Lists → Clients → Client → Overview → Primary Insurance → Group Number field


    Field 11a (Insured’s Date of Birth)

    • Lists → Clients → Client → Overview → Primary Insurance → Policy Holder Information → Date of Birth and Sex fields


    Field 11c (Insurance Plan Name or Program Name)

    • Lists → Clients → Client → Overview → Primary Insurance → Plan/Program field


    Field 11d (Is there another health benefit plan?)

    • Lists → Clients → Client → Overview → Secondary Insurance → Include Secondary Insurance on Primary Claims check box.

    Field 12 (Patient’s or Authorized Person’s Signature?)

    • This field will populate automatically with the Signature on File.


    Field 13 (Insured’s or Authorized Person’s Signature?)

    • This field will populate automatically with the Signature on File unless:
    • Lists → Claims → Claim Settings → Payers → Payer → I’m an Out-of-network provider with this payer (send payments to client) is checked. In this case, the field will be blank.

    Field 14 (Date of current Illness, Injury or Pregnancy)

    • Lists → Clients → Client → Claims Tab → Claim Defaults Button →  Date of Current Illness or Injury field, including the dropdown for Qualifier.

    Field 15 (Other Date)

    • Lists → Clients → Client → Claims Tab → Claim Defaults Button → Other Date field Including dropdown for Qualifier.


    Field 16 (Dates Patient Unable to Work in Current Occupation)

    • Lists → Clients → Client → Claims Tab → Claim Defaults Button → Dates Patient Unable to Work field (Start and End).


    Field 17 (Name of Referring Provider)

    • Lists → Clients → Client → Overview → Basic Information → Referring Provider
    • ***Field 17 information will only populate on the claim if you click the doctor symbol and select the Referring Provider from the list you created in Profile Settings.

    Field 17a (Name of Referring Provider)

    • Lists → Clients → Client → Overview → Basic Information → Referring Provider → Other ID field
    • ***Field 17 information will only populate on the claim if you click the doctor symbol and select the Referring Provider from the list you created in Profile Settings.

    Field 17b (NPI)

    • Lists → Clients → Client → Overview → Basic Information → Referring Provider → NPI field
    • ***Field 17 information will only populate on the claim if you click the doctor symbol and select the Referring Provider from the list you created in Profile Settings.

    Field 18 (Hospitalization Dates Related to Current Services)

    • Lists → Clients → Client → Claims Tab → Claim Defaults Button → Hospitalization Dates Related to Services field (Start and End).


    Field 19 (Additional Claim Information)

    • Lists → Clients → Client → Claims Tab → Claim Defaults Button → Additional Information (Box 19) field.


    Field 20 (Outside Lab)

    • Lists → Clients → Client → Claims Tab → Claim Defaults Button → Outside Lab (Yes/No).


    Field 21 (Diagnosis or Nature of Illness or Injury)

    • Lists → Clients → Client → Diagnosis Tab, OR
    • The diagnosis defined in the Note of the Date of Service being billed. 
    • Pointers A through L are defined by the order of the Diagnosis in Lists → Clients → Client → Diagnosis tab (Pointer A is the first in the list).


    Field 22 (Resubmission Code)

    • Resubmission Code:
      • Lists → Claims → Claim → Other Details → Drop Down (6, 7 or 8); 
    • Original Ref. No.:
      • Lists → Claims → Claim → Other Details → Empty Box next to dropdown.


    Field 23 (Prior Authorization Number)

    • Lists → Clients → Client → Claims Tab → Claim Defaults Button → Prior Authorization Numbers

    Field 24A (Date(s) of Service)

    • Bookings → Edit Appointment → Date


    Field 24B (Place of Service)

    • This will be tied to the Place of Service you have assigned to the Service in your Booking Settings.
    • This can be adjusted in Bookings → Booking Settings → Services → Edit the Service → CPT Codes → Place of Service (dropdown menu)


    Field 24D (CPT/HCPCS)

    • Bookings → Edit Appointment → Service
    • This can be adjusted in:
      • Bookings → Booking Settings → Services → Edit the Service → CPT Codes, OR
      • The Procedure section of the Note for the date of service in question
      • ***What you enter in More → Billing Details in the appointment dialog will populate to the Procedure section of the Note.

    Field 24D (Modifiers)

    • Bookings → Edit Appointment → Service
    • This can be adjusted in:
      • Bookings → Booking Settings → Services → Edit the Service → CPT Codes, OR
      • The Procedure section of the Note for the DOS in question, OR
      • Lists → Claims → Claim Settings → Payers → Edit Payer → CPT Overrides


    Field 24E (Diagnosis Pointer)

  • Based on what is entered in Field 21; see above.
  • Pointers will display A through L in the order they appear in the Diagnosis tab.


    Field 24F (Charges)

  • Bookings → Edit Appointment → Service
  • This can be adjusted in:
    • Bookings → Booking Settings → Services → Edit the Service → CPT Codes, OR
    • Lists → Claims → Claim Settings → Payers → Edit Payer → CPT Overrides


    Field 24G (Days or Units)

  • Bookings → Edit Appointment → Service
  • This can be adjusted in:
    • Bookings → Booking Settings → Services → Edit the Service → CPT Codes, OR
    • The Procedure section of the Note for the date of service in question.


    *Field 24H (EPSDT)

    * This value currently displays in the bottom box; it will be corrected to display in the top box.

  • Lists → Clients → Client → Claims Tab → Claim Defaults Button → EPSDT(Box 24H) field.


    Field 24I (ID. QUAL.)

  • More → Account → Clinical → Taxonomy, OR
  • Lists → Claims → Claim Settings → Payers → Edit Payer → Additional Provider IDs


    Field 24J (Rendering Provider ID#) 

  • Top box:
    • More → Account → Clinical → Taxonomy, OR 
    • Lists → Claims → Claim Settings → Payers → Edit Payer → Additional Provider IDs
  • Bottom box:
    • More → Account → Clinical → NPI (or Lists → Claims → Claim Settings → Providers)
    • Lists → Claims → Claim Settings → Payers → Edit Payer → Supervisor Relationship


    Field 25 (Federal Tax I.D.Number)

  • Lists → Claims → Claim Settings → Defaults → Tax ID field


    • Field 26 (Patient’s Account Number) 

  • The C value is found in Lists → Claims → Claim Number for date of service being billed
  • The P value is found in Lists → Clients → ID# of client  

    Example: 

    Field 27 (Accept Assignment)
  • Lists → Claims → Claim Settings → Payers → Payer → I’m an out-of network provider with this payer (send payments to client) check box 
  • If this box is checked, No will be checked in Field 27

    Field 28 (Total Charge)
  • Total of Column 24F values

    Field 29 (Amount Paid)
  • This is the amount invoiced and collected for the date of service in question.  
  • This will appear on the claim if:
    • The money is collected upfront (prior to claim creation), AND
    • Lists → Claims → Claim Settings → Defaults → Include patient paid amount on claims is checked off

    •
    Field 31 (Signature of Physician or Supplier)
  • This field will automatically fill with Signature on File from the server

    Field 32 (Service Facility Location Information)
  • Lists → Claims → Claim Settings → Facilities → Name and Address

    Field 32a (NPI)
  • Lists → Claims → Claim Settings → Facilities → NPI

    Field 32b (Service Facility Location Information)
  • Lists → Claims → Claim Settings → Facilities → Edit Facility → Facility Other ID

    Field 33 (Billing Provider)
  • Lists → Claims → Claim Settings → Defaults → Name and Address

    Field 33a (NPI)
  • Lists → Claims → Claim Settings → Defaults → NPI or Lists → Claims → Claim Settings → Payers → Edit Payer → Override Group NPI (Box 33) with Rendering Provider NPI check box

    Field 33b (Taxonomy)
  • Lists → Claims → Claim Settings → Defaults → Taxonomy