HCFA - 1500 (now called CMS-1500)
The screens in the CMS-1500 claim queue are CHF1, CHF2, CHF3 and CHF4.
In this table MMIS fields are populated with sample data to show how MMIS fields appear with valid values entered. Field entries containing Protected Health Information (PHI) appear as zeros in this example.
Table of HCFA - 1500 CHF1, CHF2, CHF3, CHF4 panels
NEXT: CHF2 HCFA-1500 - CHF1
TCN: 0 00000 00 000 0000 00
ACCOUNTING CD: 0 NORM-PAY CLAIM STATUS: N PAID
LAST CYCLE DT: MMDDYY
NPI: 0000000000 MCHP PROV NBR: 0000000 00 TYPE: 38
LAST FIRST MI
RECIPIENT ID: 00000000 NAME: LAST FIRST I
DOB: MMDDYYYY SEX: F AGE: 000 MAJOR PROG: MA LA: 00
PAT STATUS EMP: OTHER INS INFO:
PAT CONDITION RELATED TO EMP: ACCI: OTHER ACCI:
NUMBER OF RIDERS: 0 MODEL NBR: CARRIER INFO:
OVR LOC: OVR EOB/EXC: ATTACH FOUND: TPL BLNG IND:
WARRANT DATE: MMDDYY REPLACEMENT RSN: TCN REPLCD:
OBLIG ID: REPLCD BY TCN:
WARRANT NBR: 000000000 RA NBR: 000000000 TOT REIMB AMT: 000.00
LI ERR ST USER ID LI ERR ST USER ID LI ERR ST USER ID LI ERR ST USER ID
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12
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NEXT: CHF3 HCFA-1500 - CHF2
TCN: 0 00000 00 000 0000 00
ACCOUNTING CD: 0 NORM-PAY CLAIM STATUS: N PAID
MHCP PROV NBR: 0000000 00 TYPE: 00
RECIPIENT ID: 00000000 NAME: LAST FIRST I
DOB: MMDDYYYY SEX: F AGE: 000 MAJOR PROG: MA LA: 00
DT CURR ILL: DT SIMILAR ILL:
REF PROV NBR: TAXONOMY CD:
HOSP DATE FROM/TO: TRANS DEST IND:
DIAGNOSIS CODES: 000.00
PRIOR AUTH NBR: 00000000000 HOSPITAL CERT NBR:
PATIENT ACCT NBR:
TOTAL CHARGE: 000.00
PRIOR PAYMENT AMT: BALANCE DUE: 000.00
SIGNATURE: Y SECOND SIGNATURE/FACI ADDR:
DATE BILLED: MMDDYY SVC FAC NBR:
PROV NBR: 0000000000 TAXONOMY CD:
LI ERR ST USER ID LI ERR ST USER ID LI ERR ST USER ID LI ERR ST USER ID
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12
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NEXT: CHF4 HCFA-1500 - CHF3
ACCT CD: 0 NORM-PAY TCN: 0 00000 00 000 0000 00 MHCP: 0000000 00
START LINE NBR: 001 MAX LINES: 7 RECIP ID: 00000000 +
SERVICE DATES PLC --MODIFIER- SUBMITTED DAYS/ FAM
LI FROM TO SVC EMG PROC 1 2 3 4 -DIAG-- CHARGES UNITS PLAN
001 MMDDYY MMDDYY 12 T1019 1 00.00 00
TRT NPI: 0000000000 MHCP: 0000000 00 TAXONOMY CD: PA: 00000000000
NDC: QTY: OVR EOB/EXC: BASE RATE/SRC 64.96 PP
MODEL NBR: CAVITY: TOOTH:
ALLOW UNITS: 00 MSG: 543 PROV TYPE/COS: 38 038 LA: 00 FUND CD: 000
BASE RATE CHNG AMT/RSN: 0.00 01
CALC ALLOW CHG: 00.00 REIMB AMT/STAT: 00.00 B MR CODE:
002 MMDDYY MMDDYY 12 T1019 1 00.000 00
TRT NPI: 0000000000 MHCP: 0000000 00 TAXONOMY CD: PA: 00000000000
NDC: QTY: OVR EOB/EXC: BASE RATE/SRC 00.00 PP
MODEL NBR: CAVITY: TOOTH:
ALLOW UNITS: 00 MSG: 543 PROV TYPE/COS: 38 038 LA: 00 FUND CD: 00
BASE RATE CHNG AMT/RSN:
CALC ALLOW CHG: 00.00 REIMB AMT/STAT: 00.00 B MR CODE:
LI ERR ST USER ID LI ERR ST USER ID LI ERR ST USER ID LI ERR ST USER ID
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12
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NEXT: CHF1 HCFA-1500 - CHF4
TCN: 0 00000 00 000 0000 00
ACCOUNTING CD: 0 NORM-PAY CLAIM STATUS: N PAID
MHCP PROV NBR: 0000000 00 TYPE: 45 RECIP ID: 00000000
------------SERVICE FACILITY LOCATION INFORMATION ---------------
SERVICE FACILITY NAME:
ADDRESS:
CITY: STATE: ZIP:
------------BILLING PROVIDER INFORMATION -----------------------
BILLING PROVIDER NAME: PROVIDER NAME
ADDRESS: PROVIDER'S ADDRESS
CITY: STATE: MN ZIP:
LI ERR ST USER ID LI ERR ST USER ID LI ERR ST USER ID LI ERR ST USER ID
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12
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Fields on the HCFA-1500 (CMS-1500) claim
On the CHF1 panel
CLAIM STATUS field indicates the status of the claim. In this example claim status is N PAID.
TOT REIMB AMT field displays the total amount paid on this claim.
On the CHF2 panel
PRIOR AUTH NBR field displays the number of the prior authorization (in this case a service agreement) associated with this claim.
On the CHF3 panel
LI, FROM, TO, SVC, EMG, PROC, MODIFIER 1-4, DIAG, CHARGES, UNITS, PLAN fields are for each line of the claim. In this example line 001 is for PCA services (T1019). If you recall we looked at Home Care service agreements earlier in this course. This claim will decrement the Home Care service agreement line that matches the dates of service on the claim line.
As you can see there is a great deal of information on a claim. We will not go into the details of all information on a claim.
View claim information
- CLAIM PROCESSING APPLICATION INQUIRY only allows worker to view claims.
- If Section 4 on the CINQ panel is left at default of S (SUMMARY) navigation within the claim will be very limited because the F4 function key was used to navigate to the claim MMIS does not allow further navigation using the F4 key.
- Changing Section 4 to D (DETAIL) will allow use of F4 function key for additonal navigation.
- TRANSMIT to advance through the claim queue.
- Use function key F6 to return to the CRPC screen listing claims.
Next we will look at a nursing facility claim.
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