How to fill out Stedi’s CMS-1500 form for professional claims
Nov 18, 2025
Guide
A professional claim is a bill for services by a medical provider, like a doctor or therapist. You use it to bill for things like office visits, checkups, and therapy sessions.
The CMS-1500 Health Insurance Claim Form, also called the HCFA, is the standard paper form used for professional claims. If you’re mailing a claim to a payer, you’d typically use this form. It's the paper equivalent of an electronic 837P claim.
The Stedi portal’s professional claim submission form is designed to mirror the CMS-1500. It lets you submit your professional claims electronically, which is faster than mail and lets you track the claim’s status. If you need it, you can also generate a PDF CMS-1500 for any claim you submit.
This guide walks you through how to use our professional claim form in the Stedi portal. Since our form closely resembles the CMS-1500, it doubles as a reference for the paper version.
Note: This guide reflects the state of Stedi’s form at the time of publication. We’re continuing to add fields and make enhancements to the form.
How to access Stedi’s professional claim submission form
Sign in to your Stedi account and go to https://portal.stedi.com/app/healthcare/claims/create.
You can also open the form from the Stedi portal by going to Claims > Submit claim.
How Stedi’s professional claim submission form maps to the CMS-1500
Each colored block below represents a section you’ll see on both forms. The rest of this guide walks you through the fields in each section in order, with screenshots from Stedi’s form.
Field names may vary slightly between the forms. Where applicable, we’ve included the box numbers shared by both forms.
Note: Stedi’s form only supports claims to primary payers. Secondary and tertiary claims aren't supported.
Payer information
Except for the Payer field, these fields aren’t present on the CMS-1500. They’re used by Stedi to route your claim to the payer. They also indicate how the claim should be processed.
Form field | Description |
Payer | The insurer, called the payer, you’re sending the claim to. In Stedi’s form, select a payer and all relevant information will populate. In the CMS-1500, the top right corner contains the legal name and full address of the payer. |
Claim identifier | Instructs the payer how to process the claim. Most claims are Chargeable, meaning they’re sent to the payer for adjudication – review and payment. Select Reporting if you don’t want the payer to adjudicate the claim. For example, you may need to send a claim to a state agency for reporting but aren’t requesting payment. Only use Subrogation for claims sent for post-payment recovery. For example, if a payer pays their member’s medical bills after an accident caused by another driver, the payer may file a subrogation claim against the driver’s auto insurer to recover those costs. This field isn’t present on the CMS-1500. |
EDI mode | Whether you want to send a production or test claim. Production claims are sent to the payer. Test claims aren't sent to the payer, but Stedi still validates them. You’ll get a 277CA claim acknowledgment from Stedi for test claims, but you won’t receive an Electronic Remittance Advice (ERA) from the payer. This field isn’t present on the CMS-1500. |
Insurance type
Box | Field | Description |
1 | Insurance type | The type of health insurance plan being billed. Pick the type that best matches the plan and payer. For most commercial payers, select Other. Only select Medicare for claims related to Original Medicare, not Medicare Advantage plans. For Medicare Advantage, select Other. Only select Medicaid for Medicaid claims. Other available options:
The CMS-1500 includes a Group Health Plan option that isn’t available in Stedi’s professional claim form. Select Other instead. |
Insured’s information
This section includes demographic information for the insured person. It also includes information about the insurance plan in general.
The insured is the person who carries the insurance policy. They’re also called the subscriber, primary policyholder, or primary cardholder.
The insured may be a different person from the patient. For example, a spouse or dependent may be on an employee’s health insurance plan. If their spouse or child received care, the employee is still considered the insured person.
Box | Field | Description |
1a | Insured ID number | Member ID number for the insured person. This is typically found on the insurance card. For Medicare claims, this is the insured’s Medicare Beneficiary Identifier (MBI). For Payment responsibility level, select P - Primary. Stedi’s form only supports claims to primary payers. Secondary and tertiary claims aren't supported. |
4 | Insured name | Full name of the insured person. |
7 | Insured address | Mailing address for the insured person’s permanent residence. |
11 | Insured policy group or FECA number | The payer’s code for the employer or other party that purchased the plan. This is typically found on the insured person’s insurance card. For workers’ compensation claims, use the Federal Employees’ Compensation Act (FECA) number for the case. FECA numbers are always 9-character alphanumeric IDs. |
11a | Insured date of birth and sex | The insured person’s date of birth and sex. This information is used to distinguish the insured person from other members with similar names. |
11b | Other claim ID | Another ID for the insured person. It’s rare, but some payers require one in addition to the member ID in Box 1a. Use Qualifier to select the ID type:
|
11c | Insurance plan name or program name | The name of the insured person’s insurance plan. This is typically found on the insurance card. |
11d | Is there another health benefit or plan? | Stedi’s form doesn’t support Box 11d. In the CMS-1500, it indicates whether or not the patient is covered by another insurance plan. If you generate a CMS-1500 PDF for a claim submitted through Stedi, Box 11d is marked as No. |
Patient demographics
This section includes the patient’s demographic information, like name and address. It’s information that can be used to identify or contact the patient.
The patient is the person who received care. This person may be different from the insured person listed in Box 4.
Box | Field | Description |
2 | Patient name | Full name of the person who received care. |
3 | Patient DOB, Sex | Patient’s date of birth and sex. This information is used to distinguish the patient from other members with similar names. |
5 | Patient address | Mailing address for the patient’s permanent residence. |
6 | Patient Relationship to Insured | How the patient is related to the insured person listed in Box 4. |
Other insured’s information
Stedi’s form doesn’t support Box 9 and Box 9a. These boxes are used when the patient has insurance other than the plan listed in the Insured’s Information section. These fields are typically used for coordination of benefits (COB) claims.
For example, for a claim sent to the primary payer, this section would contain information for the secondary payer. For a secondary claim, it would contain information for the primary payer.
You can only use Stedi’s form to submit primary claims. If you generate a CMS-1500 PDF for a claim submitted through Stedi, Box 9 and 9a are left blank.
Condition related to work or accident
Box | Field | Description |
10a, 10b, 10c | Is patient's condition related to | Whether the patient's illness or injury is related to employment or an accident. If the illness or injury is related to an automobile accident, select Yes for Auto accident? and use State of the auto accident to select the state where the accident occurred. For automobile accidents, there may be other applicable insurance, like automobile liability insurance, that would be considered the primary payer. |
10d | Claim codes | Contains up to 4 National Uniform Claim Committee (NUCC) condition codes. A condition code is a two-character code that provides extra information about the patient’s condition or the claim itself. For example, a condition code can indicate whether the claim is part of disaster relief. For a list, see the NUCC Condition Codes list. |
Patient’s signature
Box | Field | Description |
12 | Patient or authorized person's signature | Whether the provider has the patient’s signature on file or the patient’s authorization. |
Insured’s signature
Box | Field | Description |
13 | Insured or authorized person’s signature | Whether the provider has the insured person’s signature on file or the insured person’s authorization. |
Dates of illness, injury, pregnancy, or hospitalization
Box | Field | Description |
14 | Date of Current Illness, Injury, or Pregnancy (LMP) | The date of the patient’s onset of illness, injury, or last menstrual period (LMP) before pregnancy. This date is required if:
If you include a date, use Qualifier to select the date type:
|
15 | Other date | Another date, like a last X-ray or date of the accident, related to the patient’s condition. Use Qualifier to select the date type:
|
16 | Dates patient unable to work in current occupation | Date range during which the patient was unable to work, if applicable. |
18 | Hospitalization dates related to current services | Date range during which the patient was hospitalized due to services in the claim, if applicable. Includes the patient’s admission and discharge dates. |
Referring provider
The referring provider is the provider who referred or ordered services or supplies in the claim.
Box | Field | Description |
17 | Name of referring provider | Full name of the referring provider. If multiple providers are involved, enter the full name of one provider using the following priority order:
Use Qualifier to select the type of provider entered:
|
17a, | Other ID number, NPI number | National Provider Identifier (NPI) for the referring provider. An NPI is a unique 10-digit ID issued by the Centers for Medicare & Medicaid Services (CMS) to healthcare providers. You can also enter other IDs for the referring provider. It’s rare, but some payers require these IDs in addition to the NPI. Use Qualifier to select the ID type:
|
Additional claim information
Box | Field | Description |
19a | Additional claim information | A free-text field for extra details that the payer may need to process the claim that don’t fit anywhere else on the form. Use Qualifier to select the kind of details you’re providing:
|
19b | Claim attachments | Used to include or associate the claim with attachments. Attachments are supporting documents, such as X-rays or treatment plans, that payers require before approving claims for certain services. The type of document required varies by payer and service. You can upload attachments directly in Stedi’s form. Report type is the type of attachment, such as a medical record or radiology report. See Attachment Report Type Codes for a full list. Transmission code indicates how the attachment was sent to the provider:
To submit an attachment using Stedi’s form, you must set the transmission code to EL. The Attachment control number is a unique identifier for the attachment. The payer uses this value to match the attachment to the claim. If you upload the attachment using Stedi’s form, Stedi generates the attachment control number for you. If you use Stedi’s Create Claim Attachment JSON endpoint or send the attachment using another method, you must generate the attachment control number. We recommend using a UUID of up to 50 characters. The Attachment ID is the |
Outside lab
Box | Field | Description |
20 | Outside lab | Indicates whether the services in the claim were provided by an entity other than the billing provider. |
Diagnosis or nature of illness or injury
Box | Field | Description |
21 | Diagnosis or nature of illness or injury | A list of up to 12 diagnosis codes, labeled A through L, that describe the patient’s condition. Most payers only support ICD-10-CM codes. These codes are referenced in service lines in Box 24. |
Resubmission code
Box | Field | Description |
22 | Resubmission code | Indicates whether this claim replaces or voids a previous claim. Leave this blank for original claims. Use Qualifier to indicate the Claim Frequency Code:
Include the Payer Claim Control Number (sometimes called the ICN) in the Original reference number field. See Cancel or resubmit claims for more information. |
Prior authorization number
Box | Field | Description |
23 | Prior Authorization Number | A payer-issued prior authorization number, referral number, mammography certification number, or CLIA number related to services in the claim. Use Qualifier to select the number type:
|
Service lines
Box | Field | Description |
24 | Service lines | A service line is a row that describes billing for one specific service, procedure, or supply. A claim must include at least one service line. Each service line can include:
If the service is related to family planning, select Yes for Family Planning. Otherwise, leave it blank.
|
Federal tax ID number
Box | Field | Description |
25 | Federal tax ID number | Federal tax identification number for the billing provider. You must also select the ID type: Employer Identification Number (EIN) or Social Security Number (SSN). |
Patient account number
Box | Field | Description |
26 | Patient account number | Also called the patient control number. This is the tracking ID for the claim. The payer sends back this ID in claim acknowledgments, Electronic Remittance Advice (ERAs), and claim status checks. You must provide this number. We recommend using a random, 17-character alphanumeric string. For more information, see How to track claims. |
Accept assignment
Box | Field | Description |
27 | Accept assignment | Indicates whether the billing provider agrees to be paid under the payer’s terms. Providers who are contracted with the payer are usually required to select Yes. If you select Yes, the billing provider agrees to accept the payer’s payment as payment in full, minus any patient responsibility. If you select Clinical lab only, the billing provider agrees to accept the payer’s payment as payment in full for clinical laboratory services only. This is uncommon. If you select No, the payer typically sends any payment directly to the patient, who is then responsible for reimbursing the provider. |
Total charge and amount paid
Box | Field | Description |
28 | Total charge | Total monetary amount of charges for the claim. It should be the sum of all service-line charges from Box 24. Stedi’s form calculates this for you. |
29 | Amount paid | Total monetary amount that the patient and other payers have already paid for services in the claim. |
Rendering provider signature
The rendering provider is the provider, like the doctor or therapist, who actually performed the services in the claim.
Box | Field | Description |
31 | Signature of physician or supplier | Select Yes to indicate you have the rendering provider’s signature on file. If Yes is selected, this box is filled in as SOF (Signature on file) in the generated CMS-1500 PDF. In Stedi’s form, you must also provide the following information for the rendering provider:
|
Facility provider information
A facility provider, or a service facility location, is the place where the patient receives care.
Box | Field | Description |
32 | Service facility location information | Organization name and address for the facility provider. The address should be a street address or physical location. |
32a | NPI | National Provider Identifier (NPI) for the facility provider. Only required if the facility provider’s NPI is different from the billing provider’s NPI in Box 33a. An NPI is a unique 10-digit ID issued by the Centers for Medicare & Medicaid Services (CMS) to healthcare providers. |
32b | Other IDs | Other IDs for the facility provider. It’s rare, but some payers require these IDs in addition to the NPI. Use Qualifier to select the ID type:
|
Billing provider information
The billing provider is the person or organization, like a clinic or group practice, who will receive payment (if any) for the claim from the payer.
Box | Field | Description |
33 | Billing provider information | Full name, address, and phone number for the billing provider. The address should be a street address or physical location. You can also indicate whether the billing provider is an individual or organization. |
33a | NPI | National Provider Identifier (NPI) for the billing provider. An NPI is a unique 10-digit ID issued by the Centers for Medicare & Medicaid Services (CMS) to healthcare providers. |
33b | Other IDs | Other IDs for the billing provider. It’s rare, but some payers require these IDs in addition to the NPI. Use Qualifier to select the ID type:
|
A professional claim is a bill for services by a medical provider, like a doctor or therapist. You use it to bill for things like office visits, checkups, and therapy sessions.
The CMS-1500 Health Insurance Claim Form, also called the HCFA, is the standard paper form used for professional claims. If you’re mailing a claim to a payer, you’d typically use this form. It's the paper equivalent of an electronic 837P claim.
The Stedi portal’s professional claim submission form is designed to mirror the CMS-1500. It lets you submit your professional claims electronically, which is faster than mail and lets you track the claim’s status. If you need it, you can also generate a PDF CMS-1500 for any claim you submit.
This guide walks you through how to use our professional claim form in the Stedi portal. Since our form closely resembles the CMS-1500, it doubles as a reference for the paper version.
Note: This guide reflects the state of Stedi’s form at the time of publication. We’re continuing to add fields and make enhancements to the form.
How to access Stedi’s professional claim submission form
Sign in to your Stedi account and go to https://portal.stedi.com/app/healthcare/claims/create.
You can also open the form from the Stedi portal by going to Claims > Submit claim.
How Stedi’s professional claim submission form maps to the CMS-1500
Each colored block below represents a section you’ll see on both forms. The rest of this guide walks you through the fields in each section in order, with screenshots from Stedi’s form.
Field names may vary slightly between the forms. Where applicable, we’ve included the box numbers shared by both forms.
Note: Stedi’s form only supports claims to primary payers. Secondary and tertiary claims aren't supported.
Payer information
Except for the Payer field, these fields aren’t present on the CMS-1500. They’re used by Stedi to route your claim to the payer. They also indicate how the claim should be processed.
Form field | Description |
Payer | The insurer, called the payer, you’re sending the claim to. In Stedi’s form, select a payer and all relevant information will populate. In the CMS-1500, the top right corner contains the legal name and full address of the payer. |
Claim identifier | Instructs the payer how to process the claim. Most claims are Chargeable, meaning they’re sent to the payer for adjudication – review and payment. Select Reporting if you don’t want the payer to adjudicate the claim. For example, you may need to send a claim to a state agency for reporting but aren’t requesting payment. Only use Subrogation for claims sent for post-payment recovery. For example, if a payer pays their member’s medical bills after an accident caused by another driver, the payer may file a subrogation claim against the driver’s auto insurer to recover those costs. This field isn’t present on the CMS-1500. |
EDI mode | Whether you want to send a production or test claim. Production claims are sent to the payer. Test claims aren't sent to the payer, but Stedi still validates them. You’ll get a 277CA claim acknowledgment from Stedi for test claims, but you won’t receive an Electronic Remittance Advice (ERA) from the payer. This field isn’t present on the CMS-1500. |
Insurance type
Box | Field | Description |
1 | Insurance type | The type of health insurance plan being billed. Pick the type that best matches the plan and payer. For most commercial payers, select Other. Only select Medicare for claims related to Original Medicare, not Medicare Advantage plans. For Medicare Advantage, select Other. Only select Medicaid for Medicaid claims. Other available options:
The CMS-1500 includes a Group Health Plan option that isn’t available in Stedi’s professional claim form. Select Other instead. |
Insured’s information
This section includes demographic information for the insured person. It also includes information about the insurance plan in general.
The insured is the person who carries the insurance policy. They’re also called the subscriber, primary policyholder, or primary cardholder.
The insured may be a different person from the patient. For example, a spouse or dependent may be on an employee’s health insurance plan. If their spouse or child received care, the employee is still considered the insured person.
Box | Field | Description |
1a | Insured ID number | Member ID number for the insured person. This is typically found on the insurance card. For Medicare claims, this is the insured’s Medicare Beneficiary Identifier (MBI). For Payment responsibility level, select P - Primary. Stedi’s form only supports claims to primary payers. Secondary and tertiary claims aren't supported. |
4 | Insured name | Full name of the insured person. |
7 | Insured address | Mailing address for the insured person’s permanent residence. |
11 | Insured policy group or FECA number | The payer’s code for the employer or other party that purchased the plan. This is typically found on the insured person’s insurance card. For workers’ compensation claims, use the Federal Employees’ Compensation Act (FECA) number for the case. FECA numbers are always 9-character alphanumeric IDs. |
11a | Insured date of birth and sex | The insured person’s date of birth and sex. This information is used to distinguish the insured person from other members with similar names. |
11b | Other claim ID | Another ID for the insured person. It’s rare, but some payers require one in addition to the member ID in Box 1a. Use Qualifier to select the ID type:
|
11c | Insurance plan name or program name | The name of the insured person’s insurance plan. This is typically found on the insurance card. |
11d | Is there another health benefit or plan? | Stedi’s form doesn’t support Box 11d. In the CMS-1500, it indicates whether or not the patient is covered by another insurance plan. If you generate a CMS-1500 PDF for a claim submitted through Stedi, Box 11d is marked as No. |
Patient demographics
This section includes the patient’s demographic information, like name and address. It’s information that can be used to identify or contact the patient.
The patient is the person who received care. This person may be different from the insured person listed in Box 4.
Box | Field | Description |
2 | Patient name | Full name of the person who received care. |
3 | Patient DOB, Sex | Patient’s date of birth and sex. This information is used to distinguish the patient from other members with similar names. |
5 | Patient address | Mailing address for the patient’s permanent residence. |
6 | Patient Relationship to Insured | How the patient is related to the insured person listed in Box 4. |
Other insured’s information
Stedi’s form doesn’t support Box 9 and Box 9a. These boxes are used when the patient has insurance other than the plan listed in the Insured’s Information section. These fields are typically used for coordination of benefits (COB) claims.
For example, for a claim sent to the primary payer, this section would contain information for the secondary payer. For a secondary claim, it would contain information for the primary payer.
You can only use Stedi’s form to submit primary claims. If you generate a CMS-1500 PDF for a claim submitted through Stedi, Box 9 and 9a are left blank.
Condition related to work or accident
Box | Field | Description |
10a, 10b, 10c | Is patient's condition related to | Whether the patient's illness or injury is related to employment or an accident. If the illness or injury is related to an automobile accident, select Yes for Auto accident? and use State of the auto accident to select the state where the accident occurred. For automobile accidents, there may be other applicable insurance, like automobile liability insurance, that would be considered the primary payer. |
10d | Claim codes | Contains up to 4 National Uniform Claim Committee (NUCC) condition codes. A condition code is a two-character code that provides extra information about the patient’s condition or the claim itself. For example, a condition code can indicate whether the claim is part of disaster relief. For a list, see the NUCC Condition Codes list. |
Patient’s signature
Box | Field | Description |
12 | Patient or authorized person's signature | Whether the provider has the patient’s signature on file or the patient’s authorization. |
Insured’s signature
Box | Field | Description |
13 | Insured or authorized person’s signature | Whether the provider has the insured person’s signature on file or the insured person’s authorization. |
Dates of illness, injury, pregnancy, or hospitalization
Box | Field | Description |
14 | Date of Current Illness, Injury, or Pregnancy (LMP) | The date of the patient’s onset of illness, injury, or last menstrual period (LMP) before pregnancy. This date is required if:
If you include a date, use Qualifier to select the date type:
|
15 | Other date | Another date, like a last X-ray or date of the accident, related to the patient’s condition. Use Qualifier to select the date type:
|
16 | Dates patient unable to work in current occupation | Date range during which the patient was unable to work, if applicable. |
18 | Hospitalization dates related to current services | Date range during which the patient was hospitalized due to services in the claim, if applicable. Includes the patient’s admission and discharge dates. |
Referring provider
The referring provider is the provider who referred or ordered services or supplies in the claim.
Box | Field | Description |
17 | Name of referring provider | Full name of the referring provider. If multiple providers are involved, enter the full name of one provider using the following priority order:
Use Qualifier to select the type of provider entered:
|
17a, | Other ID number, NPI number | National Provider Identifier (NPI) for the referring provider. An NPI is a unique 10-digit ID issued by the Centers for Medicare & Medicaid Services (CMS) to healthcare providers. You can also enter other IDs for the referring provider. It’s rare, but some payers require these IDs in addition to the NPI. Use Qualifier to select the ID type:
|
Additional claim information
Box | Field | Description |
19a | Additional claim information | A free-text field for extra details that the payer may need to process the claim that don’t fit anywhere else on the form. Use Qualifier to select the kind of details you’re providing:
|
19b | Claim attachments | Used to include or associate the claim with attachments. Attachments are supporting documents, such as X-rays or treatment plans, that payers require before approving claims for certain services. The type of document required varies by payer and service. You can upload attachments directly in Stedi’s form. Report type is the type of attachment, such as a medical record or radiology report. See Attachment Report Type Codes for a full list. Transmission code indicates how the attachment was sent to the provider:
To submit an attachment using Stedi’s form, you must set the transmission code to EL. The Attachment control number is a unique identifier for the attachment. The payer uses this value to match the attachment to the claim. If you upload the attachment using Stedi’s form, Stedi generates the attachment control number for you. If you use Stedi’s Create Claim Attachment JSON endpoint or send the attachment using another method, you must generate the attachment control number. We recommend using a UUID of up to 50 characters. The Attachment ID is the |
Outside lab
Box | Field | Description |
20 | Outside lab | Indicates whether the services in the claim were provided by an entity other than the billing provider. |
Diagnosis or nature of illness or injury
Box | Field | Description |
21 | Diagnosis or nature of illness or injury | A list of up to 12 diagnosis codes, labeled A through L, that describe the patient’s condition. Most payers only support ICD-10-CM codes. These codes are referenced in service lines in Box 24. |
Resubmission code
Box | Field | Description |
22 | Resubmission code | Indicates whether this claim replaces or voids a previous claim. Leave this blank for original claims. Use Qualifier to indicate the Claim Frequency Code:
Include the Payer Claim Control Number (sometimes called the ICN) in the Original reference number field. See Cancel or resubmit claims for more information. |
Prior authorization number
Box | Field | Description |
23 | Prior Authorization Number | A payer-issued prior authorization number, referral number, mammography certification number, or CLIA number related to services in the claim. Use Qualifier to select the number type:
|
Service lines
Box | Field | Description |
24 | Service lines | A service line is a row that describes billing for one specific service, procedure, or supply. A claim must include at least one service line. Each service line can include:
If the service is related to family planning, select Yes for Family Planning. Otherwise, leave it blank.
|
Federal tax ID number
Box | Field | Description |
25 | Federal tax ID number | Federal tax identification number for the billing provider. You must also select the ID type: Employer Identification Number (EIN) or Social Security Number (SSN). |
Patient account number
Box | Field | Description |
26 | Patient account number | Also called the patient control number. This is the tracking ID for the claim. The payer sends back this ID in claim acknowledgments, Electronic Remittance Advice (ERAs), and claim status checks. You must provide this number. We recommend using a random, 17-character alphanumeric string. For more information, see How to track claims. |
Accept assignment
Box | Field | Description |
27 | Accept assignment | Indicates whether the billing provider agrees to be paid under the payer’s terms. Providers who are contracted with the payer are usually required to select Yes. If you select Yes, the billing provider agrees to accept the payer’s payment as payment in full, minus any patient responsibility. If you select Clinical lab only, the billing provider agrees to accept the payer’s payment as payment in full for clinical laboratory services only. This is uncommon. If you select No, the payer typically sends any payment directly to the patient, who is then responsible for reimbursing the provider. |
Total charge and amount paid
Box | Field | Description |
28 | Total charge | Total monetary amount of charges for the claim. It should be the sum of all service-line charges from Box 24. Stedi’s form calculates this for you. |
29 | Amount paid | Total monetary amount that the patient and other payers have already paid for services in the claim. |
Rendering provider signature
The rendering provider is the provider, like the doctor or therapist, who actually performed the services in the claim.
Box | Field | Description |
31 | Signature of physician or supplier | Select Yes to indicate you have the rendering provider’s signature on file. If Yes is selected, this box is filled in as SOF (Signature on file) in the generated CMS-1500 PDF. In Stedi’s form, you must also provide the following information for the rendering provider:
|
Facility provider information
A facility provider, or a service facility location, is the place where the patient receives care.
Box | Field | Description |
32 | Service facility location information | Organization name and address for the facility provider. The address should be a street address or physical location. |
32a | NPI | National Provider Identifier (NPI) for the facility provider. Only required if the facility provider’s NPI is different from the billing provider’s NPI in Box 33a. An NPI is a unique 10-digit ID issued by the Centers for Medicare & Medicaid Services (CMS) to healthcare providers. |
32b | Other IDs | Other IDs for the facility provider. It’s rare, but some payers require these IDs in addition to the NPI. Use Qualifier to select the ID type:
|
Billing provider information
The billing provider is the person or organization, like a clinic or group practice, who will receive payment (if any) for the claim from the payer.
Box | Field | Description |
33 | Billing provider information | Full name, address, and phone number for the billing provider. The address should be a street address or physical location. You can also indicate whether the billing provider is an individual or organization. |
33a | NPI | National Provider Identifier (NPI) for the billing provider. An NPI is a unique 10-digit ID issued by the Centers for Medicare & Medicaid Services (CMS) to healthcare providers. |
33b | Other IDs | Other IDs for the billing provider. It’s rare, but some payers require these IDs in addition to the NPI. Use Qualifier to select the ID type:
|
A professional claim is a bill for services by a medical provider, like a doctor or therapist. You use it to bill for things like office visits, checkups, and therapy sessions.
The CMS-1500 Health Insurance Claim Form, also called the HCFA, is the standard paper form used for professional claims. If you’re mailing a claim to a payer, you’d typically use this form. It's the paper equivalent of an electronic 837P claim.
The Stedi portal’s professional claim submission form is designed to mirror the CMS-1500. It lets you submit your professional claims electronically, which is faster than mail and lets you track the claim’s status. If you need it, you can also generate a PDF CMS-1500 for any claim you submit.
This guide walks you through how to use our professional claim form in the Stedi portal. Since our form closely resembles the CMS-1500, it doubles as a reference for the paper version.
Note: This guide reflects the state of Stedi’s form at the time of publication. We’re continuing to add fields and make enhancements to the form.
How to access Stedi’s professional claim submission form
Sign in to your Stedi account and go to https://portal.stedi.com/app/healthcare/claims/create.
You can also open the form from the Stedi portal by going to Claims > Submit claim.
How Stedi’s professional claim submission form maps to the CMS-1500
Each colored block below represents a section you’ll see on both forms. The rest of this guide walks you through the fields in each section in order, with screenshots from Stedi’s form.
Field names may vary slightly between the forms. Where applicable, we’ve included the box numbers shared by both forms.
Note: Stedi’s form only supports claims to primary payers. Secondary and tertiary claims aren't supported.
Payer information
Except for the Payer field, these fields aren’t present on the CMS-1500. They’re used by Stedi to route your claim to the payer. They also indicate how the claim should be processed.
Form field | Description |
Payer | The insurer, called the payer, you’re sending the claim to. In Stedi’s form, select a payer and all relevant information will populate. In the CMS-1500, the top right corner contains the legal name and full address of the payer. |
Claim identifier | Instructs the payer how to process the claim. Most claims are Chargeable, meaning they’re sent to the payer for adjudication – review and payment. Select Reporting if you don’t want the payer to adjudicate the claim. For example, you may need to send a claim to a state agency for reporting but aren’t requesting payment. Only use Subrogation for claims sent for post-payment recovery. For example, if a payer pays their member’s medical bills after an accident caused by another driver, the payer may file a subrogation claim against the driver’s auto insurer to recover those costs. This field isn’t present on the CMS-1500. |
EDI mode | Whether you want to send a production or test claim. Production claims are sent to the payer. Test claims aren't sent to the payer, but Stedi still validates them. You’ll get a 277CA claim acknowledgment from Stedi for test claims, but you won’t receive an Electronic Remittance Advice (ERA) from the payer. This field isn’t present on the CMS-1500. |
Insurance type
Box | Field | Description |
1 | Insurance type | The type of health insurance plan being billed. Pick the type that best matches the plan and payer. For most commercial payers, select Other. Only select Medicare for claims related to Original Medicare, not Medicare Advantage plans. For Medicare Advantage, select Other. Only select Medicaid for Medicaid claims. Other available options:
The CMS-1500 includes a Group Health Plan option that isn’t available in Stedi’s professional claim form. Select Other instead. |
Insured’s information
This section includes demographic information for the insured person. It also includes information about the insurance plan in general.
The insured is the person who carries the insurance policy. They’re also called the subscriber, primary policyholder, or primary cardholder.
The insured may be a different person from the patient. For example, a spouse or dependent may be on an employee’s health insurance plan. If their spouse or child received care, the employee is still considered the insured person.
Box | Field | Description |
1a | Insured ID number | Member ID number for the insured person. This is typically found on the insurance card. For Medicare claims, this is the insured’s Medicare Beneficiary Identifier (MBI). For Payment responsibility level, select P - Primary. Stedi’s form only supports claims to primary payers. Secondary and tertiary claims aren't supported. |
4 | Insured name | Full name of the insured person. |
7 | Insured address | Mailing address for the insured person’s permanent residence. |
11 | Insured policy group or FECA number | The payer’s code for the employer or other party that purchased the plan. This is typically found on the insured person’s insurance card. For workers’ compensation claims, use the Federal Employees’ Compensation Act (FECA) number for the case. FECA numbers are always 9-character alphanumeric IDs. |
11a | Insured date of birth and sex | The insured person’s date of birth and sex. This information is used to distinguish the insured person from other members with similar names. |
11b | Other claim ID | Another ID for the insured person. It’s rare, but some payers require one in addition to the member ID in Box 1a. Use Qualifier to select the ID type:
|
11c | Insurance plan name or program name | The name of the insured person’s insurance plan. This is typically found on the insurance card. |
11d | Is there another health benefit or plan? | Stedi’s form doesn’t support Box 11d. In the CMS-1500, it indicates whether or not the patient is covered by another insurance plan. If you generate a CMS-1500 PDF for a claim submitted through Stedi, Box 11d is marked as No. |
Patient demographics
This section includes the patient’s demographic information, like name and address. It’s information that can be used to identify or contact the patient.
The patient is the person who received care. This person may be different from the insured person listed in Box 4.
Box | Field | Description |
2 | Patient name | Full name of the person who received care. |
3 | Patient DOB, Sex | Patient’s date of birth and sex. This information is used to distinguish the patient from other members with similar names. |
5 | Patient address | Mailing address for the patient’s permanent residence. |
6 | Patient Relationship to Insured | How the patient is related to the insured person listed in Box 4. |
Other insured’s information
Stedi’s form doesn’t support Box 9 and Box 9a. These boxes are used when the patient has insurance other than the plan listed in the Insured’s Information section. These fields are typically used for coordination of benefits (COB) claims.
For example, for a claim sent to the primary payer, this section would contain information for the secondary payer. For a secondary claim, it would contain information for the primary payer.
You can only use Stedi’s form to submit primary claims. If you generate a CMS-1500 PDF for a claim submitted through Stedi, Box 9 and 9a are left blank.
Condition related to work or accident
Box | Field | Description |
10a, 10b, 10c | Is patient's condition related to | Whether the patient's illness or injury is related to employment or an accident. If the illness or injury is related to an automobile accident, select Yes for Auto accident? and use State of the auto accident to select the state where the accident occurred. For automobile accidents, there may be other applicable insurance, like automobile liability insurance, that would be considered the primary payer. |
10d | Claim codes | Contains up to 4 National Uniform Claim Committee (NUCC) condition codes. A condition code is a two-character code that provides extra information about the patient’s condition or the claim itself. For example, a condition code can indicate whether the claim is part of disaster relief. For a list, see the NUCC Condition Codes list. |
Patient’s signature
Box | Field | Description |
12 | Patient or authorized person's signature | Whether the provider has the patient’s signature on file or the patient’s authorization. |
Insured’s signature
Box | Field | Description |
13 | Insured or authorized person’s signature | Whether the provider has the insured person’s signature on file or the insured person’s authorization. |
Dates of illness, injury, pregnancy, or hospitalization
Box | Field | Description |
14 | Date of Current Illness, Injury, or Pregnancy (LMP) | The date of the patient’s onset of illness, injury, or last menstrual period (LMP) before pregnancy. This date is required if:
If you include a date, use Qualifier to select the date type:
|
15 | Other date | Another date, like a last X-ray or date of the accident, related to the patient’s condition. Use Qualifier to select the date type:
|
16 | Dates patient unable to work in current occupation | Date range during which the patient was unable to work, if applicable. |
18 | Hospitalization dates related to current services | Date range during which the patient was hospitalized due to services in the claim, if applicable. Includes the patient’s admission and discharge dates. |
Referring provider
The referring provider is the provider who referred or ordered services or supplies in the claim.
Box | Field | Description |
17 | Name of referring provider | Full name of the referring provider. If multiple providers are involved, enter the full name of one provider using the following priority order:
Use Qualifier to select the type of provider entered:
|
17a, | Other ID number, NPI number | National Provider Identifier (NPI) for the referring provider. An NPI is a unique 10-digit ID issued by the Centers for Medicare & Medicaid Services (CMS) to healthcare providers. You can also enter other IDs for the referring provider. It’s rare, but some payers require these IDs in addition to the NPI. Use Qualifier to select the ID type:
|
Additional claim information
Box | Field | Description |
19a | Additional claim information | A free-text field for extra details that the payer may need to process the claim that don’t fit anywhere else on the form. Use Qualifier to select the kind of details you’re providing:
|
19b | Claim attachments | Used to include or associate the claim with attachments. Attachments are supporting documents, such as X-rays or treatment plans, that payers require before approving claims for certain services. The type of document required varies by payer and service. You can upload attachments directly in Stedi’s form. Report type is the type of attachment, such as a medical record or radiology report. See Attachment Report Type Codes for a full list. Transmission code indicates how the attachment was sent to the provider:
To submit an attachment using Stedi’s form, you must set the transmission code to EL. The Attachment control number is a unique identifier for the attachment. The payer uses this value to match the attachment to the claim. If you upload the attachment using Stedi’s form, Stedi generates the attachment control number for you. If you use Stedi’s Create Claim Attachment JSON endpoint or send the attachment using another method, you must generate the attachment control number. We recommend using a UUID of up to 50 characters. The Attachment ID is the |
Outside lab
Box | Field | Description |
20 | Outside lab | Indicates whether the services in the claim were provided by an entity other than the billing provider. |
Diagnosis or nature of illness or injury
Box | Field | Description |
21 | Diagnosis or nature of illness or injury | A list of up to 12 diagnosis codes, labeled A through L, that describe the patient’s condition. Most payers only support ICD-10-CM codes. These codes are referenced in service lines in Box 24. |
Resubmission code
Box | Field | Description |
22 | Resubmission code | Indicates whether this claim replaces or voids a previous claim. Leave this blank for original claims. Use Qualifier to indicate the Claim Frequency Code:
Include the Payer Claim Control Number (sometimes called the ICN) in the Original reference number field. See Cancel or resubmit claims for more information. |
Prior authorization number
Box | Field | Description |
23 | Prior Authorization Number | A payer-issued prior authorization number, referral number, mammography certification number, or CLIA number related to services in the claim. Use Qualifier to select the number type:
|
Service lines
Box | Field | Description |
24 | Service lines | A service line is a row that describes billing for one specific service, procedure, or supply. A claim must include at least one service line. Each service line can include:
If the service is related to family planning, select Yes for Family Planning. Otherwise, leave it blank.
|
Federal tax ID number
Box | Field | Description |
25 | Federal tax ID number | Federal tax identification number for the billing provider. You must also select the ID type: Employer Identification Number (EIN) or Social Security Number (SSN). |
Patient account number
Box | Field | Description |
26 | Patient account number | Also called the patient control number. This is the tracking ID for the claim. The payer sends back this ID in claim acknowledgments, Electronic Remittance Advice (ERAs), and claim status checks. You must provide this number. We recommend using a random, 17-character alphanumeric string. For more information, see How to track claims. |
Accept assignment
Box | Field | Description |
27 | Accept assignment | Indicates whether the billing provider agrees to be paid under the payer’s terms. Providers who are contracted with the payer are usually required to select Yes. If you select Yes, the billing provider agrees to accept the payer’s payment as payment in full, minus any patient responsibility. If you select Clinical lab only, the billing provider agrees to accept the payer’s payment as payment in full for clinical laboratory services only. This is uncommon. If you select No, the payer typically sends any payment directly to the patient, who is then responsible for reimbursing the provider. |
Total charge and amount paid
Box | Field | Description |
28 | Total charge | Total monetary amount of charges for the claim. It should be the sum of all service-line charges from Box 24. Stedi’s form calculates this for you. |
29 | Amount paid | Total monetary amount that the patient and other payers have already paid for services in the claim. |
Rendering provider signature
The rendering provider is the provider, like the doctor or therapist, who actually performed the services in the claim.
Box | Field | Description |
31 | Signature of physician or supplier | Select Yes to indicate you have the rendering provider’s signature on file. If Yes is selected, this box is filled in as SOF (Signature on file) in the generated CMS-1500 PDF. In Stedi’s form, you must also provide the following information for the rendering provider:
|
Facility provider information
A facility provider, or a service facility location, is the place where the patient receives care.
Box | Field | Description |
32 | Service facility location information | Organization name and address for the facility provider. The address should be a street address or physical location. |
32a | NPI | National Provider Identifier (NPI) for the facility provider. Only required if the facility provider’s NPI is different from the billing provider’s NPI in Box 33a. An NPI is a unique 10-digit ID issued by the Centers for Medicare & Medicaid Services (CMS) to healthcare providers. |
32b | Other IDs | Other IDs for the facility provider. It’s rare, but some payers require these IDs in addition to the NPI. Use Qualifier to select the ID type:
|
Billing provider information
The billing provider is the person or organization, like a clinic or group practice, who will receive payment (if any) for the claim from the payer.
Box | Field | Description |
33 | Billing provider information | Full name, address, and phone number for the billing provider. The address should be a street address or physical location. You can also indicate whether the billing provider is an individual or organization. |
33a | NPI | National Provider Identifier (NPI) for the billing provider. An NPI is a unique 10-digit ID issued by the Centers for Medicare & Medicaid Services (CMS) to healthcare providers. |
33b | Other IDs | Other IDs for the billing provider. It’s rare, but some payers require these IDs in addition to the NPI. Use Qualifier to select the ID type:
|
Share
Get started with Stedi
Get started with Stedi
Automate healthcare transactions with developer-friendly APIs that support thousands of payers. Contact us to learn more and speak to the team.
Get updates on what’s new at Stedi
Get updates on what’s new at Stedi
Get updates on what’s new at Stedi
Developers
Resources
Get updates on what’s new at Stedi
Backed by
Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.
Get updates on what’s new at Stedi
Backed by
Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.
Developers
Resources
Get updates on what’s new at Stedi
Backed by
Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.