If your agency generates the paper CMS-1500 claim form, please review this article as it describes the “mapping” of data from Penelope into the boxes contained on the 02/12 form.

As of 1st April 2014 agencies will need to use the CMS-1500 02/12 form for paper claims.

Funder

Funder name + address info. entered on Funder > Profile screen
Box 1: Type — entered on Funder > Profile screen (Funder Type field)

Patient

Box 2: Client name from Individual Profile
Box 5: Client address from Individual Profile
Box 3: Date of Birth, Gender from Individual Profile
Box 6: Relationship to insured — entered on client’s Policy screen > Members tab (e.g. Holder)
Box 10a, b & c: Employment Related, Auto Related, Other Accident — entered on Service File > CMS tab
Box 10d: Claim Codes— entered on Service File > CMS tab in Funder Specific box. NOTE If used you need to use real claim codes (defined by NUCC) and have 3 spaces between each.
Box 12: Patient Signature — will default to ‘On File’
Box 12: Date — entered on client’s Policy > Profile tab — ‘Signed On’ field

Insured

Box 1a: ID Number — Policy Member Number — entered on Policy > Members tab
Box 4 and Box 7 — Name, Address — will say ‘Same’ if client is the holder of the policy. If not, then will show information of policy holder
Box 11: Policy Number — Policy Member Group Number — entered on Policy > Members tab
Box 11a: Date of Birth, Gender — from holder’s Individual Profile
Box 11c: Plan Name — Policy Name on the client’s Policy screen — NOTE: Box 11c can be overridden by System Administrators in the CMS Setup > Setting tab
Box 11d: Other Plan — if client has secondary insurance and the secondary policy is being used for part of the event(s) being submitted on CMS, will say ‘Yes’ here. Otherwise, will say ‘No’
Box 13: Insured Signature — will default to ‘On File’

Other Insured

This information is taken from other policies in the billing sequence of the Service File (if those policies are being used for event(s) being submitted on the CMS form)

Box 9: Name — name of holder of secondary coverage
Box 9a: Policy or Group — Policy Member number on the Policy > Members tab of secondary policy
Box 9d: Plan Name — Policy Name on the Policy > Profile tab of secondary policy — NOTE: Box 9d can be overridden by System Administrators in the CMS Setup > Setting tab

Date of Illness etc

Box 14: Date of Current Illness, Injury or Pregnancy (LMP) — First Symptom Date field on client’s Service File > CMS page
Box 15: Other Date— Date of Accident on Client’s Service File > CMS page
Box 16: Unable to Work From/To — Patient Unable to Work fields on client’s Service File > CMS page
Box 17: Ref. Physician — Referring Physician name on client’s Service File > CMS page
Box 17a: Physician No. — entered on client’s Service File > CMS page
Box 18: Hosp. From/To — Hospitalization Dates fields on client’s Service File > CMS page
Box 19: Additional Claim Information (Designated by NUCC) — entered on Service File > CMS page in Funder Specific box
Box 21 ICD Ind. – denotes use of ICD9 or ICD 10 codes (as entered on the Funder Profile> EDI/CMS: ICD version field)

(A, B, C): Presenting Issue Codes 1, 2, 3 on Service File page (Participants box)
Box 23: Auth. No. — Coverage authorization number on Policy Coverage > Profile tab

Note: Symptom Start Date (box 14) and Referring Physician (box 17) can be defaulted by System Administrators in the CMS setup > Default tab.

Dates of Service etc

Box 24a: Date(s) of Service — date(s) of event(s) in Penelope
Box 24b: Place — Place of Service code from Site page
Box 24c: EMG — Emergency Service indicator — entered on Event screen > CMS box — leave blank to indicate ‘No’
Box 24d: CPT — Service Unit CPT code — entered in Service Unit screen
Mod: Modifier(s) — entered on Event screen > CMS box
Box 24e: Diag. — Diagnosis Code (Pointer) — entered on Event screen > CMS box
Box 24f: Chrg. — Billable Amount for Service Unit
Box 24g: Units — number of Service Units in cart
Box 24h: EPSDT — entered on Event screen > CMS box
Box 24i: ID — Qualifier indicating Rendering Provider number in 24j, e.g. NPI, 1D (for Medicaid Provider Number), etc. — NPI appears automatically, other qualifiers can be entered as part of Worker PINs on Worker Profile > Clinical tab
Box 24j: Rendering Provider — number related to qualifier indicated in 24i — numbers entered on Worker Profile > Clinical tab

Note: boxes 24c, 24d and 24e, as well as Modifiers, can be defaulted by System Administrators in the CMS setup > Default tab.

Federal Tax No etc

Box 25: Federal Tax No.: entered on Billing Setup > Document > Federal Tax ID Number
Box 26: Patient Account No. — Case Number followed by Invoice Number
Box 26: Patient Accepts — entered in Accept Assignment field on Policy > Profile tab
Box 31: Physician Signature — will show name of Primary Worker NOTE: Box 31 can be overridden by System Administrators in the CMS Setup > Setting tab
Box 32: Services Rendered — will show home site of Primary Worker (not site where event took place)
Box 32a: Services Rendered NPI — Agency NPI number from Agency > Profile tab
Box 32b: Services Rendered No. — entered on EDI Reference Numbers box on Agency > Profile page
Box 33: Agency Address — this is the Billing Provider — will show Agency name and Address as entered on Agency > Profile
Box 33a: Agency NPI — Agency NPI number as entered on Agency > Profile
Box 33b: Agency No. — entered on EDI Reference Numbers box on Agency > Profile page

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