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CMS 1500 — Professional Claim

HCFA-1500

Form fields follow the official CMS 1500 (02-12) claim format

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Drop a PDF/image here, or click to browse — AI will extract and populate all fields automatically
A
Boxes 1–13 — Patient & Insured Information
Box 1 Insurance Type
1a Insured's ID Number
2 Patient's Name (Last, First, MI)
3 Patient DOB / Sex
4 Insured's Name (if different)
5 Patient's Address
6 Patient Relationship to Insured
7 Insured's Address
8 Patient Status
9 Other Insured's Name (Secondary Coverage)
10 Is Patient's Condition Related To:
11 Insured's Policy Group / FECA #
12 Patient's Signature Date
13 Insured's Authorization Signature
B
Boxes 14–23 — Condition Information
14 Date of Current Illness / Injury
15 Other Date (if applicable)
16 Dates Patient Unable to Work
17 Referring Provider Name & NPI
17a/b Referring NPI
18 Hospitalization Dates
19 Additional Claim Information
20 Outside Lab? / 21 Diagnosis Codes (ICD-10)
22 Resubmission Code / Original Ref #
23 Prior Authorization Number
C
Box 24 — Service Lines (A–J)
# A. Date From A. Date To B. POS C. EMG D. CPT/HCPCS D. Modifier E. Diag Ptr F. Charges G. Units H. EPSDT I. ID Qual J. NPI
1
2
3
D
Boxes 25–33 — Provider & Billing Information
25 Federal Tax ID (EIN/SSN)
26 Patient Account #
27 Accept Assignment?
28 Total Charge
29 Amount Paid
30 Reserved for NUCC Use
31 Signature of Physician
31 Date Signed
32 Service Facility Name & Address
32a Service Facility NPI
32b Other ID
33 Billing Provider Name & Address
33a Billing Provider NPI
33b Other Provider ID
Total Charges: $470.00 Lines: 2 of 6
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AI Assistant

The CMS 1500 (HCFA-1500) is the standard paper claim form for professional services. This page digitizes that form with full validation.

  • Use AI Document Scan to auto-fill from scanned paper claims
  • All boxes map directly to the official CMS 1500 form fields
  • Validation checks run before submission
  • Box 1 — Check the primary insurance type
  • Box 1a — Medicare ID or insurance member number
  • Box 2 — Patient name exactly as it appears on ID card
  • Box 3 — Date of birth in MM/DD/YYYY format
  • Box 11 — Required for COB coordination
  • Box 13 — SOF = Signature on File (most common)
  • Col A — Dates of service (from/to)
  • Col B — Place of Service code (11=Office, 21=Inpatient, 23=ER)
  • Col D — CPT/HCPCS procedure code + up to 4 modifiers
  • Col E — Diagnosis pointer (A, B, C… links to Box 21)
  • Col F — Submitted charge amount
  • Col J — Rendering provider NPI

Upload a scanned CMS 1500 image (PDF, JPG, or PNG). The AI engine will:

  • Detect the form type automatically
  • Extract all field values using OCR + NLP
  • Show confidence scores for each extracted field
  • Allow manual correction before final submission

Low-confidence fields will be highlighted in amber for review.