Quick reference for each CMS box number and what information it should contain.
| Box # | Box Name | What the Box States / Required Info |
|---|---|---|
| 1 | Insurance Type | Select the type of insurance for this claim (Medicare, Medicaid, Commercial, Self-pay, etc.). |
| 2 | Patient Full Name | Enter the patient’s full legal name exactly as it appears on the insurance card (Last, First, Middle). |
| 3 | Patient DOB & Sex | Enter the patient’s date of birth and indicate gender as shown in the payer records. |
| 4 | Insured Name | Enter the name of the insured (policy holder) if different from the patient. |
| 5 | Patient Address | Enter the patient’s complete mailing address, including street, city, state, and ZIP code. |
| 6 | Relationship to Insured | Indicate whether the patient is self, spouse, child, or other relative of the insured. |
| 7 | Insured Address | Enter the insured’s complete mailing address, if different from the patient’s. |
| 8 | Patient Status | Indicate marital and employment/student status (single/married, employed, full-time student, etc.). |
| 9 | Other Insured Name | If there is secondary or other coverage, enter the other insured’s full name. |
| 10 | Condition Related To | Indicate whether the illness/injury is related to employment, auto accident, or other accident. |
| 11 | Insured Policy Details | Enter the insured’s policy, group number, or FECA number as required by the payer. |
| 12 | Patient Authorization | Indicates the patient’s or authorized person’s signature for release of medical information. |
| 13 | Payment Assignment | Indicates if the insured or authorized person authorizes payment of benefits to the provider. |
| 14 | Date of Current Illness | Enter the date when the current illness, injury, or pregnancy began. |
| 15 | Other Date | Used for other relevant dates, such as first symptom or similar condition onset date, if required. |
| 16 | Dates Patient Unable to Work | Enter from–to dates when the patient was unable to work in current occupation, if applicable. |
| 17 | Referring Provider Name | Enter the name of the referring or ordering provider associated with this service. |
| 18 | Hospitalization Dates | If applicable, enter the from–to dates of any related inpatient hospitalization. |
| 19 | Additional Claim Info | Used for payer-specific notes or additional claim information as instructed by the payer. |
| 20 | Outside Lab | Indicate if an outside lab was used and enter total lab charges if required. |
| 21 | Diagnosis Codes | Enter the primary and additional ICD diagnosis codes related to this claim. |
| 22 | Resubmission / Original Ref | For resubmissions, enter the payer’s original claim reference or resubmission code if required. |
| 23 | Prior Authorization | Enter the prior authorization number or referral number, when required by the payer. |
| 24 | Service Line Details | Contains the detailed service lines including dates of service, place of service, procedures, modifiers, charges, units, and rendering provider. |
| 25 | Provider Tax ID | Enter the billing provider’s federal tax ID number (EIN or SSN) and mark the appropriate type. |
| 26 | Patient Account Number | Enter the internal patient account number used by the billing provider for tracking. |
| 27 | Accept Assignment | Indicates whether the provider agrees to accept assignment of benefits as payment in full, per payer rules. |
| 28 | Total Charge | Enter the total billed charge for all service lines on this claim. |
| 29 | Amount Paid | Enter any amount already paid by the patient or other payers before this claim. |
| 30 | Balance Due | Enter the remaining balance due (total charge minus amount paid), if required by payer. |
| 31 | Provider Signature & Date | Indicates the provider’s signature (or signature on file) and the date the claim was signed. |
| 32 | Service Facility Location | Enter the name, address, and NPI of the facility where services were actually rendered, if different from billing location. |
| 33 | Billing Provider Info | Enter the billing provider’s name, full address, phone number, and NPI/PTAN as required by the payer. |