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CMS-1500 / 837P Electronic Claim
1
Patient & Payer
2
Service Lines
3
Diagnoses
4
Review & Submit
Patient Information
Patient Name
Date of Birth
Member / Subscriber ID
Group Number
Payer & Service Details
Payer
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BlueCross BlueShield PPO
UnitedHealthcare Choice Plus
Aetna CVS Health
Cigna Open Access Plus
Humana HMO
Medicare Part B
Medicaid — California
Date of Service
Place of Service
11 - Office
21 - Inpatient Hospital
22 - Outpatient Hospital
23 - Emergency Room
81 - Independent Laboratory
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