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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! 🎁

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.


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?

This can be done from a few places! The most common are the Patient Profile (Billing> Insurance Policies> View> Edit) or from the Appointment Panel if you’re in the Schedule (Insurance Info> click the downward-facing arrow next to the Policy name> Edit 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.

Next, you can head into the Staff Profile’s Billing section to find their Default and Insurance Specific Claim IDs.



Insurer Settings

Question: Where is the claim being sent?

Where is this on the CMS1500?

Where is this in Jane?

If you head into your Settings and then down to Insurers, you’ll be able to click Edit to the right of an existing Insurer to see the address the claim will be sent to. Or, if you are creating a New Insurer, you’ll have the opportunity to add an address.



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.

🔥 Hot Tip: you can add, search, or ‘favorite’ Billing Codes in your Settings.


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).

🔥 Hot Tip: You can assign fees to your CPT codes in your Settings under Billing Codes.


Question: Have any payments been made toward the services yet?

Where is this on the CMS1500?

Where is this in Jane?

There are a few different places you’ll find this, but if you take a look at the Billing Info section of the Appointment Panel, you’ll be able to find any Payments that have been applied to that Appointment.


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 make a group submission from the Insurance section of your Billing tab.



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

Group 2

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

There are two places this information may live in Jane. The first is the Clinic Info & Locations (in Settings). When you create a New Location, or an existing one, there is a place to enter the NPI and a Billing Address for where the money should be sent.

The second is the Staff Profile Billing tab. You can View or Add New Default or Insurance Specific Claim Information, including separate Billing Address, Tax ID Number/Type, NPIs, Taxonomy Codes.

Group 2

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). Some Insurers require that both Box 12 and Box 13 be left blank, and Box 27 checked as ‘No’ in order to have the patient directly reimbursed. However, there is no clear definition/rule that applies to all Insurers, so it’s best to contact specific Insurance companies to learn how to format your claims in order for the patient to be reimbursed.


Question: Where was the service performed?

Where is this on the CMS1500?

Where is this in Jane?

This can be found in the Clinic Info & Location area of your Settings. Jane will use your Clinic/Practice Name that you enter under Clinic Info. When you click Edit on your Location, you’ll find or be able to add the Location Name, Location Address, NPI, and Place of Service code.