Jane's Guide Here's all the help you need to use Jane.

Insurance Claims & The CMS1500

Have you ever had questions about the information that’s included in an insurance claim? Where can certain things be found on the CMS1500 and where does it come from in Jane? 💭

If so, this guide is for you! 🎁

💡Heads up — while CMS1500 forms can be created on the Balance, Practice, or Thrive subscription plans, entering in insurance-specific information is only available with the insurance add-on on the Practice or Thrive Plan.

If you are looking for a detailed breakdown of what needs to be included in each box of the CMS1500— and exactly how to enter that information into Jane— check out our CMS1500 Reference Sheet.

Before we get started, a bit of background…

The CMS1500 form is the standard paper claim form that organizations & individuals use to bill insurance for services and products. Services and products are each billed with appropriate CPT codes.

The CMS1500 can be thought of as the paper version of an electronic (or 837) submission. It contains all of the information that an insurance company requires to process a claim for an encounter.

According to CMS, the form is the standard claim form used by non-institutional providers— such as a Jane clinic or an individual practitioner— to bill Medicare Part B claims. It is also used for billing some Medicaid State Agencies. Many commercial insurance companies also accept CMS1500 forms as valid claim submissions.

For more on the CMS1500, you can check out our Insurance Billing Training guide on Creating a CMS1500.

Let’s go!

Below, we’ve answered some of the questions you may ask yourself about insurance claims, the CMS1500, and Jane. Feel free to click through, or scroll down to check out the entire list!

The Patient Profile

Question: Who is the Patient?

Where is this answered on the CMS1500?

Where is this answered in Jane?

Under the Edit/Settings tab of the Patient Profile, you can find or add demographic information, including a Patient’s Name, DOB, Legal Sex, and Address. These demographics will populate through to any billed claims automatically.

Question: Who holds the Primary Insurance Policy and what are the Policy details? Do they have additional coverage? If yes, what are those Policy details?

Where is this on the CMS1500?

Where is this in Jane?

This is a big one! While you’re in that Patient Profile, head into their Billing tab and then into the Insurance Policies section. Now you can create a New Insurance Policy or click View> Edit to see the details of an existing one.

Question: Are there any other providers (excluding the Rendering and Billing Provider) involved in the services?

Where is this on the CMS1500?

Where is this in Jane?

Many disciplines are required to add a referring provider including their NPI to claims billed.

This can be set up in the patient’s insurance policy, which can be added or modified in a few places – but commonly added from the billing area of the patient’s profile. Here, under Insurance Policies you can either set up your fresh policy or View and then Edit and existing policy. Near the bottom of the Policy, you’ll find a drop-down box where you can choose any other providers involved and add their ID numbers.

The Staff Profile

Question: Who rendered the services and what are their credentials?

Where is this on the CMS1500?

Where is this in Jane?

From the Staff Profile, you can first head into Edit/Settings to find the First Name, Last Name, Prefix, and Credentials of the provider in question. This will populate how the provider’s name is displayed in Box 31.

Next, you can head into the Staff Profile’s Billing section to find their Default and Insurance Specific Claim IDs. Feel free to check out our US Insurance Setup Guide that covers this in more detail:

US Insurance Billing Training: Step 3 – Staff & Location Info

💡Pro Tip: If you’re credentialed differently with different insurers, you can customize what information populates to claims under Insurance Specific Claim Information. This could be a differing NPI, Tax ID number, or billing provider details.

Insurer Settings

Question: Where is the claim being sent?

Where is this on the CMS1500?

Where is this in Jane?

Under the Insurers section of your Settings, you’ll be able to create new insurers or modify an existing one. For electronic submissions, the Payer ID is what communicates with the Clearinghouse where the claim should be sent. If you’re submitting via paper CMS-1500, you can also add the insurer’s address here too.

💡Pro Tip: If you’re not sure which Payer ID to use for your electronic submission, it will usually listed on the back of your patient’s insurance card. You can also have your patients add this information through their intake form, too!

The Appointment Panel

Question: What diagnosis is being treated?

Where is this on the CMS1500?

Where is this in Jane?

Diagnosis Codes can be found and added directly into the Insurance Info section of the Appointment Panel.

💡Pro Tip: you can add, search, or ‘favorite’ Billing Codes in your Settings. Clicking the space bar when adding a code will show you a list of your favorited codes.

Question: Which treatment services were performed, when were they performed, and what are the charges?

Where is this on the CMS1500?

Where is this in Jane?

The answers to these questions can be found in the Appointment Panel. The date the service was performed will automatically be the date of the Appointment on the Schedule.

Which services were performed— and the charges for those services— will be determined by the CPT and diagnosis codes added to the Insurance Info section of the Appointment Panel (see image above).

💡Pro Tip: You can also add your CPT (procedure) and ICD-10 (diagnosis) codes while you’re doing your charting: Adding CPT & Diagnosis Codes to Charts on the U.S. Insurance Plan

Question: Has this claim been submitted before?

Where is this on the CMS1500?

Where is this in Jane?

This can be seen from the Appointment Panel when you hit Submit on a claim. It can also be found when you generate a claim submission from the Claim Submission Folders under Billing.

When reviewing the claim pre-submission, if a claim has been previously generated you can add any resubmission or correction codes, as well as the reference/claim control number. For more information on this process, check out our guide on Managing Resubmissions & Corrected Claims

Clinic Info & Location

Question: Who should be reimbursed for the services, and where should that money be sent?

Where is this on the CMS1500?

Group 1: Insurer pays the clinic

Group 2: Insurer pays the patient

Where is this in Jane?

The first group of boxes (25 & 33) gives the Insurer the billing provider’s info and a location to send the money if the provider would like to be reimbursed. However, if you’d like the patient to be reimbursed, then the second group of boxes is also important.

Group 1

The default place that the Billing Provider details and Tax ID number pull from is under Locations, which can be found in your Settings. Here, you can set up the standard information that should populate when an appointment is scheduled into this location – including fields like NPI (Billing Provider & Service Facility Location), tax ID number, place of service codes, and taxonomy codes.

If you’d like to populate custom information on a per-provider or per-insurer basis, you can also add fields like tax ID (Box 25) and Billing Provider details (Box 33) under the Billing section of a staff member’s profile.

Group 2

If you’re a clinic that offers Courtesy Billing, where you submit the claim and would like the reimbursement from the insurer to go to the patient directly, this is for you! While there isn’t a standardized way around how information should be submitted, there seems to be a relationship between Box 12, Box 13, and Box 27 of the CMS1500. This relationship can determine who gets reimbursed for the services (patient or provider).

💡Pro Tip: If you’re not sure how to populate these boxes to indicate to an insurer that you’d like the patient to be reimbursed, or you’ve received payment from an insurer – we’d recommend reaching out to the insurer directly who will be able to give you guidance around how they’d like these claims to be submitted.

Question: Where was the service performed?

Where is this on the CMS1500?

Where is this in Jane?

The Service Facility Location information (including address & location NPI) is a representation of the physical space that the service was rendered. This information lives (and can be updated) in Settings, under Locations. The specific language pulls from a couple of fields here, including the clinic name, the location name, location address, and billing settings. For a more specific breakdown of these fields, take a peek at our guide on Box 32.

The Place of Service code can be added here in Locations under Settings, too. You can also set treatment-specific Place of Service Codes when editing your treatments under Treatments, Classes & Group Appointments in Settings.

Subscribe to our monthly newsletter.