How to Fill the HCFA Claim Form in zHealth
How to Fill the HCFA Form (CMS-1500)
This guide outlines the mapping between the fields in zHealthEHR and the corresponding fields on the HCFA (CMS-1500) Insurance Claim Form. The HCFA form is the standard insurance claim form used by chiropractic practices and other non-hospital healthcare providers to bill both government and commercial insurance payers for services rendered.
This document provides step-by-step instructions on how to accurately enter, update, or modify the relevant information in your zHealth account to ensure the correct data is submitted with each claim. It explains where to input or edit information in zHealth and clarifies the purpose of each field on the HCFA form.
If you need managed billing services, contact our team at sales@zhealthehr.com.
Box #1 — Insurance Plan Type
Indicates the type of insurance the claim is being submitted to: Medicare, Medicaid, CHAMPUS, CHAMPVA, Group Health Plan, FECA Black Lung, or Other. "Other" includes HMOs, Commercial insurance, Automobile accident, Liability, and Workers' compensation.
This is a one-time configuration set up at the Insurance level.
- Go to Facility Settings > Insurance Tab
- Search the insurance company
- Click the "Edit" icon
- In the Claim Filing Indicator field, choose the appropriate option from the dropdown
Once configured, the system will automatically populate Box #1 on the claim form.
Editing Rights: Not Editable/View Only
Box #1a — Insured's I.D. Number
The insured's identification number and prefix for the payer to which the claim is being submitted.
The system retrieves the insured's identification number (Member ID/Subscriber ID) from the patient's profile.
- Go to the Contact Details of the Patient's Profile
- Go to the Primary/Secondary/Tertiary Insurance
- Enter the subscriber ID in the Member ID field (with the prefix if required)
Editing Rights: Can edit HCFA and will override/save in patient chart
Box #2 — Patient's Name
The patient's full name, including any suffixes. Last Name / First Name / Middle Initial.
The system retrieves the patient's full name from the patient's profile.
- Go to the Patient's Profile
- Go to Contact Details tab > Personal Information section
- Enter the Patient Full Name
Editing Rights: Can edit HCFA and will override/save in patient chart
Box #3 — Patient Birth Date and Sex
The patient's birth date (MM/DD/YYYY) and sex/gender. The payer does not accept "other" as gender.
- Go to Patient Profile > Contact Details
- Under Personal Information, update the Date of Birth and Sex fields
- Click Save
Editing Rights: Can edit HCFA and will override/save in patient chart
Box #4 — Insured's Name
Required when the patient is a dependent. If the patient is the insured, their name should also be entered here.
- If the patient is the policyholder: Patient Profile > Contact Details > Personal Information > Patient's Full Name
- If the policyholder is someone other than the patient: Patient Profile > Contact Details > Primary Insurance > Relation to Insured (Spouse/Child/Other) > Insured's Full Name
Editing Rights: Can edit HCFA and will override/save in patient chart
Box 5 — Patient's Address
Street Number, City, State, ZIP, and Phone Number.
Patient's Profile > Contact Details > Personal Information > Patient's Home Address & Home Phone > Save.
Editing Rights: Can edit HCFA and will override/save in patient chart
Box 6 — Patient Relationship to Insured
Indicates the relationship between the patient and the insured: Self, Spouse, Child, or Other.
Patient Profile > Contact Details > Primary Insurance > Relation to Insured (Self, Child, Other, or Spouse) > Save.
Editing Rights: Not Editable/View Only
Box 7 — Insured's Address
The insured's current home address: street, city, state, ZIP.
- If the policyholder is the patient: Patient Profile > Contact Details > Personal Information > Address & Home Phone Number > Save
- If the policyholder is someone other than the patient: Patient Profile > Contact Details > Primary Insurance > Relation to Insured > Insured's Address > Save
Editing Rights: Can edit HCFA and will override/save in patient chart
Box 8 — Reserved for NUCC Use
Previously used to report "Patient Status." No entry is required. Reserved for future NUCC use.
Editing Rights: Not Editable/View Only
Box 9 — Other Insured's Name
Indicates there is another policy (e.g., secondary insurance) that may cover the patient. Completed when there is more than one insurance policy on the patient case (along with 9a and 9d).
- If the patient is the policyholder for the other policy: Patient Profile > Contact Details > Personal Information > Patient's Full Name > Save
- If someone other than the patient: Patient Profile > Contact Details > Secondary or Tertiary Insurance > Relation to Insured > Insured's Full Name > Save
Editing Rights: Not Editable/View Only
Box 9a — Other Insured's Policy or Group Number
The other insured's policy or group number for coverage in addition to the primary policy.
Note: "Insured's Policy" or "Group Number" must be filled under Primary and Secondary Insurance for this to auto-populate.
Patient Profile > Contact Details > Secondary/Tertiary Insurance > Member ID # > Save.
Editing Rights: Not Editable/View Only
Box 9b & 9c — Reserved for NUCC Use
Both fields have been eliminated (formerly "Other Insured's Date of Birth, Sex" and "Employer's Name or School Name").
Editing Rights: Not Editable/View Only
Box 9d — Insurance Plan Name or Program Name
The other policy's insurance or program name.
Note: "Plan Number" must be filled under Primary and Secondary Insurance for this to auto-populate.
Patient Profile > Contact Details > Secondary or Tertiary Insurance > Plan > Save.
Editing Rights: Can fill it from the CMS-1500 form
Box 10a, 10b & 10c — Is Patient's Condition Related To
- 10a — Employment (Current or Previous): Patient Profile > Contact Details > Primary Insurance > Yes/No for "Employment?" > Save
- 10b — Auto Accident: Patient Profile > Contact Details > Primary Insurance > Yes/No for "Auto Accident?" > Save
- 10c — Other Accident: Patient Profile > Contact Details > Primary Insurance > Yes/No for "Other Accident?" > Save
Editing Rights: Not Editable/View Only
Box 10d — Claim Codes
Identifies additional information about the patient's condition or claim, using the applicable Claim Codes designated by the NUCC. Refer to www.nucc.org (Code Sets) for the current Condition Codes.
Editing Rights: Not Editable/View Only
Box 11 — Insured's Policy, Group, or FECA Number
The policy, group, or FECA number for the insured. Boxes 11, 11a–11d correspond to whichever policy (primary or secondary) is currently being billed.
Patient Profile > Contact Details > Primary/Secondary/Tertiary Insurance > Group # of the insurance policy being billed > Save.
Editing Rights: Not specified as view-only in source; treat as system-populated from Insurance record.
Box 11a — Insured's Date of Birth, Sex
8-digit date of birth (MMDDYYYY) and the insured's gender.
- If the patient is the policyholder: Patient Profile > Contact Details > Personal Information > Patient's Date of Birth & Gender > Save
- If someone other than the patient: Patient Profile > Contact Details > Primary/Secondary/Tertiary Insurance > Relation to Insured > Insured's Date of Birth & Gender > Save
Editing Rights: Can edit HCFA only (will NOT save to patient chart)
Box 11b — Other Claim ID
If the condition relates to Workers' Comp/Employment, Auto Accident, or Other Accident, enter the Claim # under the Insurance section in the patient's profile — it will pull through automatically. Claim identifiers are designated by the NUCC.
Editing Rights: Can edit HCFA only (will NOT save to patient chart)
Box 11c — Insurance Plan Name or Program Name
The name of the insurance plan/program being billed.
Patient Profile > Contact Details > Primary/Secondary/Tertiary Insurance > Insurance Plan Name > Save.
Editing Rights: Can edit HCFA only (will NOT save to patient chart)
Box 11d — Is There Another Health Benefit Plan
Automatically checked "No" if only one insurance policy is present, or "Yes" if more than one is present.
Editing Rights: Can edit HCFA only (will NOT save to patient chart)
Box 12 — Patient's or Authorized Person's Signature
Automatically formatted to print "Signature on File" and the date.
Box 13 — Insured's or Authorized Person's Signature
Automatically populated by zHealth with "Signature on File."
Box 14 — Date of Current Illness, Injury, or Pregnancy
The first date of onset of illness or actual date of injury (MM/DD/YY or MM/DD/YYYY).
Patient Profile > Patient Billing > open the relevant Invoice > enter Initial Treatment Date or Date of Injury > Recalculate & Save.
Editing Rights: Can edit HCFA and will override/save in patient chart
Box 15 — Other Date
Populates from the invoice: Initial Treatment date first, then Acute Treatment date if Initial is blank, then Accident date if both are blank. A date can also be picked manually from the dropdown on the HCFA for that DOS if it exists on the invoice.
Editing Rights: Can edit HCFA and will override/save in patient chart
Box 16 — Dates Patient Unable to Work in Current Occupation
The time span the patient is/was unable to work, if employed.
Editing Rights: Cannot be modified within zHealthEHR
Box 17 — Name of Referring Provider or Other Source
The referring, ordering, or supervising provider for the service(s)/supply(ies).
Patient chart > Contact Details tab > Primary Insurance tab > add referring physician details and select the correct qualifier.
Editing Rights: Can edit HCFA only (will NOT save to patient chart)
Box 17a — ID Number of Referring Provider
The referring provider's State License Number, UPIN Number, or Provider Commercial Number.
Patient Profile > Contact Details > Primary Insurance > Box 17 Physician Other ID > Save.
Editing Rights: Can edit HCFA only (will NOT save to patient chart)
Box 17b — NPI
The NPI (National Provider Identifier) of the referring, ordering, or supervising provider.
Patient Profile > Contact Details > Primary Insurance > Box 17 Physician NPI Number > Save.
Editing Rights: Can edit HCFA only (will NOT save to patient chart)
Box 18 — Hospitalization Dates Related to Current Services
Inpatient stay admission and discharge dates.
Editing Rights: Cannot be modified in zHealthEHR
Box 19 — Additional Claim Information
Additional information about the patient's condition or claim, per the payer's current instructions. Report the appropriate qualifier with no space, hyphen, or separator between qualifier and information.
Editing Rights: Can edit from the HCFA Form directly
Box 20 — Outside Lab, $ Charges
Indicates whether an outside laboratory performed services. For routine chiropractic services, this box is generally left unused.
Editing Rights: Can edit from the HCFA Form directly
Box 21 — Diagnosis or Nature of Illness/Injury (ICD Ind.)
The applicable ICD indicator specifying the ICD code version. Up to 12 unique diagnosis codes per claim, limited to 4 diagnosis pointers per procedure.
Pulled from the invoice: Patient Profile > Patient Billing > select Invoice > Diagnosis > Recalculate & Save.
Editing Rights: Cannot edit the ICD-10 codes from the HCFA-1500 form
Box 22 — Resubmission Code, Original Ref. No.
The original reference number for resubmitted/corrected claims.
- 1 – Original: any original claim, and always for all Medicare claims
- 7 – Resubmission/Replacement: always for BC/BS corrected claims and/or resubmissions
- 6 – Corrected Claim: not used or accepted
- 8 – Void/Cancel of Prior Claim
Editing Rights: Can edit HCFA only (will NOT save to patient chart)
Box 23 — Prior Authorization Number
The payer-assigned authorization number, if required. Must be set up in the patient's insurance record beforehand.
Patient chart > Contact Details > Primary Insurance > Prior Authorization Number > Save. Select qualifier G1 (Quality Improvement Organisation).
Editing Rights: Cannot edit from the HCFA Form directly
Box 24A — Date of Service
Populated from the invoice: Patient Profile > Patient Billing > select Invoice > CPT Code section > DOS From / DOS To > Save.
Editing Rights: Cannot edit from the HCFA Form directly
Box 24B — Place of Service
Patient Profile > Patient Billing > select Invoice > CPT Code section > select POS > Save.
Editing Rights: Cannot edit from the HCFA Form directly
Box 24C — EMG
Identifies if the service was an emergency. Automatically defaults to "No."
Editing Rights: Can edit HCFA only (will NOT save to patient chart)
Box 24D — Procedures, Services, or Supplies
CPT code(s) in effect on the date of service.
Patient Profile > Patient Billing > select Invoice > Procedure Service Line (CPT Code) > enter code and modifier > Save.
Editing Rights: Cannot edit from the HCFA Form directly
Box 24E — Diagnostic Pointer
Links the diagnosis code(s) in Box 21 to the procedure performed.
Patient Profile > Patient Billing > select Invoice > Procedure Service Line > Diagnosis Pointers > Save.
Editing Rights: Cannot edit from the HCFA Form directly
Box 24F — Charges
Total billed amount per service line.
Patient Profile > Patient Billing > select Invoice > Procedure Service Line > Charges > Save.
Editing Rights: Cannot edit from the HCFA Form directly
Box 24G — Days or Units
Number of units for the service; defaults to the unit(s) set on the procedure code record unless changed manually.
Patient Profile > Patient Billing > select Invoice > Procedure Service Line > Units > Recalculate & Save.
Editing Rights: Cannot edit from the HCFA Form directly
Box 24H — EPSDT Family Plan
Identifies certain services that may be covered under some state plans.
Editing Rights: Not Editable/View Only — cannot be modified in zHealth
Box 24I — ID Qualifier
The appropriate qualifier for the ID listed in the shaded 24J area for the Rendering Provider.
- User Name > Facility Settings > Insurances > find record > Edit > Other ID – HCFA 1500 Box 24I (shaded) > select Qualifier (0B, 1G, G2, X5, ZZ, or LU) > Save
- Confirm qualifiers are also filled at Facility level (Facility Settings > Facility > Additional Identifications) and Provider level (Facility Settings > Provider > Additional Identifications)
Editing Rights: Cannot edit from the HCFA Form directly
Box 24J — Rendering Provider ID#
The ID of the individual performing/rendering the service.
Dashboard > User Name > Facility Settings > Provider > Provider Details > NPI > Save.
Editing Rights: Cannot edit from the HCFA Form directly
Box 25 — Federal Tax I.D. Number
The Federal Tax ID (EIN or SSN) of the Billing Provider.
Dashboard > User Name > Facility Settings > Provider > Provider Details > Provider Tax ID > Save. Choose "Bill with EIN" or "Bill with SSN" and enter the corresponding number.
Editing Rights: Cannot edit from the HCFA Form directly
Box 26 — Patient's Account Number
The identifier assigned by the provider; automatically generated in zHealth.
Editing Rights: Cannot edit from the HCFA Form directly
Box 27 — Accept Assignment?
Indicates that the provider agrees to accept assignment under the terms of the payer's program.
Set at the Insurance level: Facility Settings > Insurances > find Insurance Record > Edit > Accept Reassignment > select the appropriate option > Save.
Note: When accepting assignment, the beneficiary may be billed for the 20% coinsurance, any unmet deductible, and services not covered by Medicare. The difference between the billed amount and the Medicare-approved amount cannot be billed. The 20% coinsurance is based on 20% of the Medicare-approved amount (not 20% of the billed amount).
Editing Rights: Can edit from the HCFA Form directly and will override the Master Insurance "Accept Reassignment" field.
Box 28 — Total Charge
Total billed amount for all services entered in Box 24F. Negative amounts are not allowed; no dollar signs; enter "00" in the cents field for whole numbers.
Editing Rights: Cannot edit from the HCFA Form directly
Box 29 — Amount Paid
The payment received from the patient or other payers for covered services.
Note: The system automatically fills Box 29 when the claim is submitted to secondary insurance, based on the primary payer's paid amount from the primary remittances.
Editing Rights: Cannot edit from the HCFA Form directly
Box 30 — Reserved for NUCC
Designated use is not currently defined. Previously used for Balance Due; that use has been eliminated.
Editing Rights: Cannot edit from the HCFA Form directly
Box 31 — Signature of Physician or Supplier
The authorized/accountable person and their degree, credentials, or title.
Check the "Signed" box and enter the 8-digit date, or complete a SOAP note and click Review & Sign > Sign Note — this auto-formats to "Signature on File" with the claim submission date.
Editing Rights: Can edit from the HCFA Form directly
Box 32 — Service Facility Location Information
The name and address of the facility where services were rendered.
Pulled from Dashboard > User Name > Facility Settings > Provider > Provider Details > Address.
Editing Rights: Cannot edit from the HCFA Form directly
Box 32a — NPI
The HIPAA National Provider Identifier number.
Facility Settings > Insurances > find record > Edit > Advanced Options > CMS-1500 32a Entity Type > Save.
Editing Rights: Cannot edit from the HCFA Form directly
Box 32b — Non-NPI ID
The non-NPI ID number of the service facility, assigned by the payer.
- Facility Settings > Facility > Facility Details: fill out State License Number (0B) and Provider Taxonomy Number (ZZ); repeat at Provider level. Also fill out Provider Commercial Number (G2) and Location Number (LU) under Provider > Additional Identifications.
- Facility Settings > Insurances > find record > Edit > Other ID – HCFA 1500 Box 32B > select Qualifier (0B, G2, or LU) > Save.
- Insurance record > Edit > Advanced Options > select the CMS-1500 33b Entity Type > Save.
Editing Rights: Cannot edit from the HCFA Form directly
Box 33 — Billing Provider Info & Phone Number
The billing provider's/supplier's billing name, address, ZIP, and phone number.
Facility Settings > Insurances > find record > Edit > Advanced Options > CMS-1500 33 Entity Type (including Box 25) > Save. "Organization" uses the practice's info; "Individual" uses the provider's info.
Editing Rights: Cannot edit from the HCFA Form directly
Box 33a — Billing Provider NPI
Typically the practice's NPI, unless billing as an individual.
Facility Settings > Insurances > find record > Edit > Advanced Options > CMS-1500 33a Entity Type > Save. "Organization" uses the Practice NPI; "Individual" uses the Provider NPI. This can be overridden for a specific insurance company.
Editing Rights: Cannot edit from the HCFA Form directly
Box 33b — Billing Provider Group #
The payer-assigned unique identifier of the billing provider. Typically the practice's Group #, if billing as part of a group.
- Facility Settings > Facility > Facility Details: fill out State License Number (0B) and Provider Taxonomy Number (ZZ); repeat at Provider level. Also fill out Provider Commercial Number (G2) and Location Number (LU).
- Facility Settings > Insurances > find record > Edit > Billing Provider Other ID – HCFA 1500 Box 33B > select Qualifier (0B, G2, or LU) > Save.
- Insurance record > Edit > Advanced Options > select the CMS-1500 33b Entity Type > Save.
Editing Rights: Cannot edit from the HCFA Form directly