Facility Claim Form Overview
  • 18 Mar 2024
  • 31 Minutes to read
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Facility Claim Form Overview

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Article summary

The electronic UB-04 form used in contemporary healthcare billing is based on the paper UB-04 form, which is an institutional claim form for submitting insurance claims. The Claim.MD online version of the UB-04 retains the familiar layout of the paper form while incorporating electronic elements supported in the ANSI X12 837I electronic claim standard, which is specific to institutional claims. This document provides a comprehensive description of each field on the UB-04 claim form and offers a correlation to their corresponding electronic components.

The paper version of the claim form (UB04) can be visually compared to identify the differences.

Claim.MD Facility Claim Form (as seen on the View/Edit Claims page)

Facility Claim- Block 1
Billing Provider Information


Field Name

Billing Provider Name

DescriptionThe name of the billing provider or the entity responsible for submitting the claim. This could be the name of a group practice or facility.
Paper Claim Block1
Required / SituationalSituational
XML / JSON Fieldbill_name
X12 Loop / Segment2010AA / NM103
Allowed Values32 characters
NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search
Field Name

Billing Provider Address 1, Billing Provider Address 2

DescriptionThe address of the billing provider or the entity responsible for submitting the claim.
Paper Claim Block1
Required / SituationalRequired
XML / JSON Fieldbill_addr_1, bill_addr_2
X12 Loop / SegmentLoop 2010BB / N301 /N302
Allowed Values128 characters
NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search
Field Name

Billing Provider City

Description

The city where the billing provider is located.

Paper Claim Block1
Required / SituationalRequired
XML / JSON Fieldbill_city
X12 Loop / SegmentLoop 2010AA - NM401
Allowed Values32 characters
NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search
Field Name

Billing Provider State

DescriptionThe state where the billing provider is located.
Paper Claim Block1
Required / SituationalRequired
XML / JSON Fieldbill_state
X12 Loop / SegmentLoop 2010AA - NM402
Allowed ValuesTwo-letter state codes (e.g., CA, NY, TX).
NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search
Field Name

Billing Provider Zip Code

DescriptionThe ZIP code of the billing provider's location.
Paper Claim Block1
Required / SituationalRequired
XML / JSON Fieldbill_zip
X12 Loop / SegmentLoop 2010AA - NM403
Allowed Values12 characters
NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search
Field Name

Billing Provider Phone Number

DescriptionThe phone number of the billing provider or the entity submitting the claim. This can include the area code.
Paper Claim Block1
Required / SituationalRequired
XML / JSON Fieldbill_phone
X12 Loop / SegmentLoop 2010AA - PER04
Allowed Values16 characters
NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search
Field Name

Pay-To-Provider Address 1, Pay-To-Provider Address 2

DescriptionThis specifies the address of the provider or entity to whom payment should be directed for the services rendered.
Paper Claim Block1a (also 2)
Required / SituationalSituational
XML / JSON Fieldpay_addr_1, pay_addr_2
X12 Loop / SegmentLoop 2010AA- N301, N302
Allowed Values55 characters
Notes
Field Name

Pay To Provider City

DescriptionThis specifies the city of the provider or entity to whom payment should be directed for the services rendered.
Paper Claim Block1a (also 2)
Required / SituationalSituational
XML / JSON Fieldpay_city
X12 Loop / SegmentLoop 2010AA- N401
Allowed Values30 characters
Notes
Field Name

Pay To Provider State

DescriptionThis specifies the city of the provider or entity to whom payment should be directed for the services rendered.
Paper Claim Block1a (also 2)
Required / SituationalSituational
XML / JSON Fieldpay_state
X12 Loop / SegmentLoop 2010AA- N402
Allowed Values2 characters
Notes
Field Name

Pay To Provider Zip Code

DescriptionThis specifies the zip code of the provider or entity to whom payment should be directed for the services rendered.
Paper Claim Block1a (also 2)
Required / SituationalSituational
XML / JSON Fieldpay_zip
X12 Loop / SegmentLoop 2010AA- N403
Allowed Values12 characters
Notes
Field Name

Facility Name

DescriptionThis specifies the name of the facility where the services were provided to the patient.
Paper Claim Block1b
Required / SituationalSituational
XML / JSON Fieldfacility_name
X12 Loop / SegmentLoop 2010AB- NM103
Allowed Values32 characters
Notes
Field Name

Facility Address, Facility Address 2

DescriptionThis specifies the address of the facility where the services were provided to the patient.
Paper Claim Block1b
Required / SituationalSituational
XML / JSON Fieldfacility_addr_1, facility_addr_2
X12 Loop / SegmentLoop 2010AB-N301, N302
Allowed Values64 characters
Notes
Field Name

Facility City

DescriptionThis specifies the city of the facility where the services were provided to the patient.
Paper Claim Block1b
Required / SituationalSituational
XML / JSON Fieldfacility_city
X12 Loop / SegmentLoop 2010AA- N401
Allowed Values32 characters
Notes
Field Name

Facility State

DescriptionThis specifies the state of the facility where the services were provided to the patient.
Paper Claim Block1b
Required / SituationalSituational
XML / JSON Fieldfacility_state
X12 Loop / SegmentLoop 2010AA- N402
Allowed Values2 characters
Notes
Field Name

Facility Zip Code

DescriptionThis specifies the zip code of the facility where the services were provided to the patient.
Paper Claim Block1b
Required / SituationalSituational
XML / JSON Fieldfacility_zip
X12 Loop / SegmentLoop 2010AA- N403
Allowed Values12 characters
Notes
Field Name

Facility NPI

DescriptionThis specifies the NPI of the facility where the services were provided to the patient.
Paper Claim Block1b
Required / SituationalSituational
XML / JSON Fieldfacility_npi
X12 Loop / SegmentLoop 2010AA-REF02
Allowed Values12 characters
Notes


Facility Claim- Block 2-9
Patient Control Number, Medical Record Number, Type of Bill, Fed. Tax No, Statement From-Thru, Patient Information


Field Name

PCN (Patient Control Number)

DescriptionThis field is used to capture a unique identifier assigned by the provider to the patient. It is often utilized to link the claim information to the patient's records within the provider's system, allowing for better tracking and management of healthcare services and billing.
Paper Claim Block3a
Required / SituationalRequired
XML / JSON Fieldpcn
X12 Loop / SegmentLoop 2300 - CLM01
Allowed Values32 characters
NotesThis is either decided by the biller (usually following a convention) or generated from a PMS/EMR system.
Field Name

MRN (Medical Record Number)

DescriptionThis captures the patient's unique identification number within the healthcare provider's system. While the PCN is specifically to link the patient to claim information, the MRN often links the patient information to their medical history.
Paper Claim Block3b
Required / SituationalSituational
XML / JSON Fieldmrn
X12 Loop / SegmentLoop 2300- REF02
Allowed Values32 characters
Notes
Field Name

Type of Bill (NUBC Type of Bill)

DescriptionThe "Type of Bill" code identifies the specific category or type of service for which the claim is being submitted. This code helps the payer categorize and process the claim correctly. The "Type of Bill" code is essential for determining the appropriate payment and adjudication processes for the submitted claim.
Paper Claim Block4
Required / SituationalRequired
XML / JSON Fieldtype_of_bill
X12 Loop / Segment2300 -

CLM05-1 (Value 11 – Inpatient, 13 –Outpatient, or 18 – Critical Access Hospitals/Swing Beds for Sub-Acute Care)

CLM05-2 (Value A – Uniform Billing Claim Form Bill Type)

CLM05-3 (Value 1 – Original Bill, 7 –Request for Adjustment, or 8 – Request for Void of Previous Bill)

Allowed Values3 characters
Notes
Field Name

Billing Provider Tax ID (EIN)

DescriptionThis block is used to provide the federal tax identification number (TIN) of the billing entity or provider.
Paper Claim Block5
Required / SituationalRequired
XML / JSON Fieldbill_taxid
X12 Loop / SegmentLoop 2010AA - 

REF01 (Value EI – Employer ID)

REF02 (Tax ID)

Allowed Values16 characters
Notes
Field Name

Statement From Date, Statement Thru Date

Description This is used to indicate the start and end dates of the billing period for the services being claimed.
Paper Claim Block6
Required / SituationalRequired
XML / JSON Fieldfdos, ldos
X12 Loop / SegmentLoop 2300 - 

DTP01 (Qualifier 434 – Statement)

DTP02 (Value D8, Format:

CCYYMMDD or RD8 – Date Range)

DTP03 (Date or Dates)

Allowed ValuesDate yyyymmdd
Notes
>
Field name not displayed
Field Name

Reserved for Assignment by the NUBC



DescriptionN/A
Paper Claim Block7
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / Segment

N/A

Allowed ValuesN/A
Notes
Field Name

Patient Name (Last, First, Middle initial)

Description
Paper Claim Block8
Required / Situationallast name and first name required
XML / JSON Fieldpat_name_l, pat_name_f, pat_name_m
X12 Loop / SegmentLoop 2010BA if 2010CA is not sent - NM103 (Last Name), NM104 (First Name), NM105 (Middle Name)
Allowed Values35 characters (last name), 25 characters (first name), 25 characters (middle initial)
Notes
Field Name

Patient Address, Patient Address 2

DescriptionThis captures the street address of the patient for communication and identification purposes.
Paper Claim Block9
Required / SituationalRequired (Address 1 only)
XML / JSON Fieldpat_addr_1, pat_addr_2
X12 Loop / SegmentLoop 2010BA if 2010CA is not sent  - N301
Allowed Values55 characters
Notes
Field Name

Patient City

DescriptionThis captures the city residence of the patient for communication and identification purposes.
Paper Claim Block9
Required / SituationalRequired
XML / JSON Fieldpat_city
X12 Loop / SegmentLoop 2010BA if 2010CA is not sent  - N401
Allowed Values30 characters
Notes
Field Name

Patient State

DescriptionThis captures the state residence of the patient for communication and identification purposes.
Paper Claim Block9
Required / SituationalRequired
XML / JSON Fieldpat_state
X12 Loop / SegmentLoop 2010BA if 2010CA is not sent  - N402
Allowed Values2 characters
Notes
Field NamePatient Zip Code
DescriptionThis captures the zip code residence of the patient for communication and identification purposes.
Paper Claim Block9
Required / SituationalRequired
XML / JSON Fieldpat_zip
X12 Loop / SegmentLoop 2010BA if 2010CA is not sent  - N403
Allowed Values15 characters
Notes
Field Name

Patient Country Code

DescriptionThis captures the country of the patient for communication and identification purposes.
Paper Claim Block9
Required / SituationalRequired
XML / JSON Fieldpat_country
X12 Loop / SegmentLoop 2010BA if 2010CA is not sent  - N404
Allowed Values2 characters
Notes
Facility Claim- Block 10-17
Patient Information, Admit & Discharge Information


Field Name

Patient Date of Birth

DescriptionThis is used to capture the "Birthdate" of the patient, providing essential demographic information for healthcare identification and record-keeping.
Paper Claim Block10
Required / SituationalRequired
XML / JSON Fieldpat_dob
X12 Loop / Segment

Loop 2010BA if 2010CA is not sent - DMG01 (Value D8 – Format:CCYYMMDD), DMG02 (Birthdate)

Allowed Values10 characters
Notes
Field Name

Patient Gender

DescriptionUsed to indicate the gender of the patient, aiding in accurate patient identification and healthcare record management.
Paper Claim Block11
Required / SituationalRequired
XML / JSON Fieldpat_sex
X12 Loop / SegmentLoop 2010BA if 2010CA is not sent - DMG03 (Value M – Male, F – Female or U – Unknown)
Allowed Values1 character (M/F/U
Notes
Field Name

Admitting Date

DescriptionRefers to the date when a patient was admitted to the healthcare facility for treatment or services, providing critical information for billing and claims processing.
Paper Claim Block12
Required / SituationalRequired
XML / JSON Fieldhosp_from_date
X12 Loop / SegmentLoop 2300 - DTP01 (Qualifier 435 – Statement), DTP02 (Value D8 – Format: CCYYMMDD or DT – Format

CCYYMMDDHHMM), DTP 03 (Single Date or Date Range)

Allowed ValuesDate yyyymmdd
Notes
Field Name

Admitting Hour 00-24

DescriptionCaptures the hour at which a patient was admitted to the healthcare facility, providing a more detailed timestamp for admission information on the claim form.
Paper Claim Block13
Required / SituationalRequired
XML / JSON Fieldadmit_hour
X12 Loop / SegmentLoop 2300 - DTP01 (Qualifier 435 – Statement), DTP02 (Value D8 – Format: CCYYMMDD or DT – Format

CCYYMMDDHHMM), DTP 03 (Single Date or Date Range)

Allowed ValuesNumeric 2.0
Notes
Field Name

Admitting Hour 00-24

DescriptionCaptures the hour at which a patient was admitted to the healthcare facility, providing a more detailed timestamp for admission information on the claim form.
Paper Claim Block13
Required / SituationalRequired
XML / JSON Fieldadmit_hour
X12 Loop / SegmentLoop 2300 - DTP01 (Qualifier 435 – Statement), DTP02 (Value D8 – Format: CCYYMMDD or DT – Format

CCYYMMDDHHMM), DTP 03 (Single Date or Date Range)

Allowed ValuesNumeric 2.0
Notes
Field Name

Admit Type

DescriptionCaptures the category or reason for a patient's admission to a healthcare facility, such as emergency, elective, newborn, etc., providing important contextual information for billing and patient care.
Paper Claim Block14
Required / SituationalRequired
XML / JSON Fieldadmit_type
X12 Loop / SegmentLoop 2300 - CL101
Allowed Values1 character
Notes
Field Name

Admit Source

DescriptionCaptures the hour at which a patient was admitted to the healthcare facility, providing a more detailed timestamp for admission information on the claim form.
Paper Claim Block13
Required / SituationalRequired
XML / JSON Fieldadmit_source
X12 Loop / SegmentLoop 2300 - CL102
Allowed Values1 character
Notes
Field Name

Discharge Hour 00-24

DescriptionCaptures the hour at which a patient was admitted to the healthcare facility, providing a more detailed timestamp for admission information on the claim form.
Paper Claim Block16
Required / SituationalRequired
XML / JSON Fielddisch_hour
X12 Loop / Segment

DTP01 (Qualifier 096 – Discharge), DTP02 (Value TM – Format HHMM), DTP 03 (Time)


Allowed ValuesNumeric 2.0
Notes
Field Name

Discharge Status

DescriptionDischarge status in healthcare refers to the condition under which a patient leaves a healthcare facility. It indicates the patient's health status at the time of discharge and provides important information for care coordination, billing, and post-hospitalization planning.
Paper Claim Block17
Required / SituationalRequired
XML / JSON Fielddisch_status
X12 Loop / Segment

CL103 (Status Code)

Allowed ValuesNumeric 2.0
Notes2 characters


Facility Claim- Block 18-41
Condition Codes, Occurrence Codes, Value Codes
Field Name

Condition Codes

DescriptionA "Condition Code" is a numerical identifier used to convey specific situations, such as a patient's urgent admission (code 17), or patient's admission for observation (code 41), during their healthcare facility stay, aiding in accurate billing and claims processing.
Paper Claim Block18-28
Required / SituationalSituational
XML / JSON Fieldcond_code_1
X12 Loop / Segment

Loop 2300 - HI01-1 (Value BG – Condition), HI01-2 (Condition Code)

Allowed Values2 characters
Notes
Field Name

ACDT State

Field not displayed on form
Description

Refers to the state where the "Accident Date" (ACDT) occurred, which is the date when an accident or injury leading to the patient's medical condition took place. It aids in accurate billing, claims processing, and documentation of the circumstances surrounding the patient's condition.

Paper Claim Block29
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / Segment

Loop 2300 - HI01-1 (Value BG – Condition), HI01-2 (Condition Code)

Allowed Values2 characters
Notes
Field Name

Reserved for Assignment by NUBC

Field not displayed on form
DescriptionN/A
Paper Claim Block30
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / Segment

N/A

Allowed ValuesN/A
Notes
Field Name

Occurrence Code 1-8; Occurrence Date 1-8

Description"Occurrence Code" is a numerical identifier used to convey specific events or circumstances during a patient's stay, such as reporting an occurrence of a significant event (code 25) or a date of the last menstrual period (code 50), aiding in accurate billing and claims processing.
Paper Claim Block31-36
Required / SituationalSituational
XML / JSON Fieldocc_code_1, occ_code_2, occ_code_3, occ_code_4, occ_code_5, occ_code_6, occ_code_7, occ_code_8
occ_date_1_date, occ_date_2_date, occ_date_3_date, occ_date_4_date, occ_date_5_date, occ_date_6_date, occ_date_7_date, occ_date_8_date
X12 Loop / Segment

HI01-1 (Value BH – Occurrence), HI01-2 (Occurrence Code – see notes), HI01-3 (Value D8 – Format: CCYYMMDD), HI01-4 (Date)

Allowed Values2 characters (Occurrence Code), Date yyyymmdd (Occurrence Date)
Notes
Field Name

Reserved for Assignment by NUBC

Field not displayed on form
DescriptionN/A
Paper Claim Block37
Required / SituationalN/A
XML / JSON FieldN/A
X12 Loop / Segment

N/A

Allowed ValuesN/A
Notes

Field not displayed in Claim.MD form

Field Name

Responsible Party Name/Address

DescriptionRefers to the identification and contact information of the individual or entity responsible for the patient's medical expenses, enabling accurate communication, billing, and claims processing for the party responsible for covering the incurred healthcare costs.
Paper Claim Block38
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / Segment

2000B - SBR01 (Value P – Primary), SBR09 (Value WC – Worker’s Comp)

Allowed ValuesN/A
Notes
Field Name

Value Codes / Value Amount

Description"Value Code and Amount" is a numeric code and corresponding monetary amount used to provide additional information about specific aspects of a patient's care, such as reporting the amount of covered days in skilled nursing (code 80) or the purchase price of a piece of durable medical equipment (code 77), aiding in accurate billing and claims processing.
Paper Claim Block39-41
Required / SituationalSituational
XML / JSON Fieldvalue_code_1, value_code_2, value_code_3, value_code_4, value_code_5, value_code_6, value_code_7, value_code_8
value_amt_1, value_amt_2, value_amt_3, value_amt_4, value_amt_5, value_amt_6, value_amt_7, value_amt_8
X12 Loop / Segment

Loop 2300 - HI01-1 (Value BE – Value Code), HI01-2 (Value Code), HI01-5 (Amount)

Allowed Values2 characters (Value
Notes


Facility Claim- Block 42-48
Rev Code, HCPC, Charges, NDC
Field Name

Revenue Code

DescriptionA "Revenue Code" is a numerical code used to classify specific healthcare services or items provided to a patient, such as inpatient room and board (code 100), pharmacy services (code 250), or laboratory services (code 300), helping in accurate billing and categorization of services on the UB-04 claim form.
Paper Claim Block42
Required / SituationalRequired
XML / JSON Fieldrev_code
X12 Loop / Segment

Loop 2400 - SV201 (Service Line Revenue Code)

Allowed Values5 characters
NotesRefer to the NUBC UB-04 Data Specifications Manual for specific code references

Field Name

HCPC Description (Additional Narrative)

DescriptionRevenue Description/I DE Number/Medicaid Drug Rebate/ Line Level Rendering Provider NPI.
Paper Claim Block43
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / Segment

Loop 2400 - SV202-7 (Description)

Allowed ValuesN/A
NotesRefer to the NUBC UB-04 Data Specifications Manual for specific code references
Field Name

HCPC (procedure codes)

DescriptionHCPC  in Block 44 of the UB-04 claim form involve reporting specific medical procedures or services, such as "99213" for an outpatient office visit,.
Paper Claim Block44
Required / SituationalRequired
XML / JSON Fieldproc_code
X12 Loop / Segment

SV202-1 (Value HC – HCPCS or HP –HIPPS), SV202-2 (Procedure Code)

NotesCPT Codes references:  

Field Name

Accommodation Rate Amount

DescriptionBlock 44 on the UB-04 claim form involves reporting the "Accommodation Rate," which pertains to the rate associated specifically with a room and board revenue code, aiding in accurate billing and claims processing.
Paper Claim Block44
Required / SituationalSituational
XML / JSON Field

SV202-1 (Value HC – HCPCS or HP –HIPPS), SV202-2 (Procedure Code)

X12 Loop / Segmentrate
Allowed ValuesNumeric 8.2
NotesRefer to the NUBC UB-04 Data Specifications Manual for specific code references
Field Name

Modifiers

DescriptionHCPCS modifiers are two-character codes appended to procedure codes to convey specific details about a healthcare service, such as "-GT" for telehealth services, enhancing accurate billing and claims processing.
Paper Claim Block44
Required / SituationalSituational
XML / JSON Fieldmod1, mod2, mod3, mod4
X12 Loop / Segment

SV202-3 through SV202-6 (Modifiers)

Allowed Values2 characters
Notes
Field Name

Service Date

Description "Dates of Service," is the date when services were first provided.
Paper Claim Block45
Required / SituationalRequired
XML / JSON Fieldfrom_date
X12 Loop / Segment

Loop 2400 - DTP01 (Value 472 – Service date), DTP02 (Value D8 – Format:, CCYYMMDD or RD8 – Date Range)DTP03 (Date or Dates)

Allowed ValuesDate yyyymmdd
Notes
Field Name

Units (Service Units)

DescriptionThis captures the quantity of healthcare services provided, such as "5" for inpatient days or "3" for outpatient visits, crucial for precise billing and claims processing.
Paper Claim Block46
Required / SituationalRequired
XML / JSON Fieldunits
X12 Loop / Segment

Loop 2400 - SV204 (Value DA – Days or UN –Units), SV205 (Service Unit Count)

Allowed Values(dropdown UN/DA) and 6 characters for number of units
Notes
Field Name

Charge Amount

DescriptionThis field is used for reporting the specific charge associated with the specific service provided, ensuring accurate billing and claims processing.
Paper Claim Block47
Required / SituationalRequired
XML / JSON Fieldcharge
X12 Loop / Segment

Loop 2400 - SV203 (Line item charge amount)

Allowed ValuesNumeric 9.2
Notes
Field Name

COB Non-Covered Amount

Description"Non-covered charges" refer to healthcare services or items that are not eligible for reimbursement or coverage by an insurance plan or payer, requiring patients to bear the financial responsibility for those specific expenses.
Paper Claim Block48
Required / SituationalSituational
XML / JSON Fieldtotal_non_covered
X12 Loop / Segment

Loop 2400- SV207 (Line Item Denied Charge or Non-Covered Charge Amount)

Allowed ValuesNumeric 10.2
Notes
Field Name

Total Charge Amount

DescriptionThe "Total Charge Amount" represents the sum of all charges associated with the healthcare services provided to a patient, reflecting the full cost of care before any adjustments, discounts, or insurance payments are applied.
Paper Claim Block47
Required / SituationalRequired
XML / JSON Fieldtotal_charge
X12 Loop / SegmentLoop 2400 - SV203 (Line item charge amount)
Allowed ValuesNumeric 12.2
NotesThis field will automatically add up all the charges in the individual charge lines for the specific procedures/services.
Field Name

NDC Code / Dosage / Measure

DescriptionNDC (National Drug Code) is a standardized numeric identifier used to uniquely identify pharmaceutical products for accurate tracking, documentation, and billing in the healthcare system.
The NDC (National Drug Code) dosage and measure refer to the specific dosage strength and measurement unit associated with a pharmaceutical product identified by its NDC code, aiding in accurate prescription and administration of medications.
Paper Claim BlockN/A *under block 47
Required / SituationalSituational
XML / JSON Fieldndc_code, ndc_dosage, ndc_measure
X12 Loop / SegmentN/A
Allowed Values11 characters (code) 7 characters (dosage), 2 (measure)
NotesNDC Code References:
http://www.accessdata.fda.gov/
https://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=ndc


Facility Claim- Block 49-57
Payer Information, Relationship, Est. AMount Due, NPI, Taxonomy


Field Name

Reserved for Assignment by NUBC

Field not displayed on form
DescriptionThis is intended for future use or designation by the National Uniform Billing Committee (NUBC), which is responsible for maintaining and revising the UB-04 claim form and associated standards.
Paper Claim BlockN/A
Required / SituationalN/A
XML / JSON FieldN/A
X12 Loop / SegmentN/A
Allowed ValuesN/A
NotesSee the NUBC guide
Field Name

Payer Name

DescriptionRefers to the name of the entity responsible for providing insurance coverage or making payments for healthcare services, enabling proper identification and communication in the claims and billing process.
Paper Claim Block50
Required / SituationalRequired
XML / JSON Fieldpayer_name
X12 Loop / Segment2010BB -NM101 (Value PR – Payer), NM102 (Value 2 – Non-person), NM103 (Payer Name)
Allowed Values64 characters
Notes
Field Name

Payer ID

DescriptionThe unique identifier assigned to an insurance company or payer, used to accurately route and process healthcare claims, ensuring efficient communication and reimbursement between healthcare providers and payers.
Paper Claim Block51
Required / SituationalRequired
XML / JSON Fieldpayerid
X12 Loop / Segment2010BB - NM108 (Value PI – Payer ID), NM109 (NDWSI)
Allowed Values64 characters
NotesInformation obtained from insurance card or directly from insurance provider.
See Claim.MD payer list for a searchable list of payers already in the Claim.MD database. 
XLSX: https://www.claim.md/payer_list.xlsx
Field Name

Release of Information

DescriptionRefers to the patient's consent or authorization to allow their medical information to be shared with authorized parties, such as healthcare providers and insurance companies, for purposes of billing, claims processing, and other healthcare-related activities.
Paper Claim Block52
Required / SituationalSituational
XML / JSON Field
X12 Loop / Segment2300 - Information 2300 CLM09
Allowed Valuesdropdown (Yes, signed or Informed Consent)
Notes
Field Name

Assignment of Benefits

DescriptionThis indicates whether the healthcare provider agrees to accept the insurance payment as full reimbursement for covered services, alleviating the patient from any additional financial responsibility beyond their deductible, copayment, or coinsurance.
Paper Claim Block53
Required / SituationalRequired
XML / JSON Fieldaccept_assign
X12 Loop / SegmentLoop 2300 - CLM07 (Value A – Assigned), CLM08 (Value Y – Yes)
Allowed Values1 character (Y/N)
Notes
Field Name

Prior Payments

Field not displayed on form
DescriptionIndicates that the healthcare provider acknowledges any previous payments made by the patient or other sources toward the billed services, helping to ensure accurate billing and claims processing.
Paper Claim Block54
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / SegmentLoop 2300 - AMT01 (Value C4 – Prior Payment). AMT02 (Amount)
Allowed ValuesN/A
Notes
Field Name

Estimated Amount Due

DescriptionRefers to the projected or anticipated sum that the patient is expected to pay for healthcare services after accounting for insurance coverage, deductibles, coinsurance, and any previous payments, helping patients understand their financial responsibility and facilitating transparent billing practices.
Paper Claim Block55
Required / SituationalSituational
XML / JSON Field
X12 Loop / Segment

Loop 2300 AMT01 (Value C5 – Claim Amount Due Estimated), AMT02 (Amount)

Allowed Values
Notes
Field Name

NPI

DescriptionThis is used to report the "National Provider Identifier" (NPI) of the attending physician or non-physician practitioner who supervised the patient's care during their stay, ensuring accurate identification and billing of the responsible healthcare provider.
Paper Claim Block56
Required / SituationalRequired
XML / JSON Fieldprov2_npi
X12 Loop / Segment2010AA - NM108 (Value XX), NM109 (NPI)
Allowed Values10 numeric
NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search
Field Name

Taxonomy (or Other Prvoider ID)

DescriptionDesignated for reporting the "Healthcare Provider Taxonomy Code" associated with the attending physician or non-physician practitioner, which classifies their specific healthcare specialty or profession, aiding in accurate identification and categorization of the provider for billing and claims processing.
It can also be designated as an additional identifier used to uniquely identify a healthcare provider. This identifier can be different from the primary identifier (such as the National Provider Identifier or NPI) and is often used for specific purposes, such as cross-referencing with other systems, tracking purposes, or billing and claims processing. It helps ensure accurate and efficient communication between healthcare entities and payers.
Paper Claim Block57
Required / SituationalSituational
XML / JSON Fieldprov2_taxonomy
X12 Loop / Segment2010AA - NM108 (Value XX), NM109 (NPI)
Allowed Values10 characters
Notes
Facility Claim- Block 58-62
Insured's Information


Field Name

Insured's Name (Last Name, First Name, Middle Name)

DescriptionRefers to the name of the individual covered by the insurance plan, facilitating accurate identification and claims processing.
Paper Claim Block58
Required / SituationalSituational
XML / JSON Fieldins_name_l, ins_name_f, ins_name_m
X12 Loop / Segment2010BA -NM101 (Value IL – Insured), NM102 (Value 1 – Person or 2 –Organization), NM103 (Organization or Last Name), NM104 (First Name), NM105 (Middle Name)
Allowed Values35 characters (last name), 25 characters (first name), 25 characters (middle)
Notes
Field Name

Patient Relationship

DescriptionDesignated for reporting the "Healthcare Provider Taxonomy Code" associated with the attending physician or non-physician practitioner, which classifies their specific healthcare specialty or profession, aiding in accurate identification and categorization of the provider for billing and claims processing.
Paper Claim Block59
Required / SituationalRequired
XML / JSON Fieldpat_rel
X12 Loop / Segment2000B - SBR02 (Value 18 – Self or 20 – Workers’ Comp)
Allowed Values2 characters (dropdown)
Notes
Field Name

Insured ID (Policy Number) 

DescriptionRefers to the unique identifier associated with the insured individual, aiding in accurate identification and claims processing.
Paper Claim Block60
Required / SituationalRequired
XML / JSON Fieldins_number
X12 Loop / Segment

2010BA Or 2010CA - NM108 (Value MI – Member ID), NM109 (WSI Claim Number) Or REF01 (Value Y4 – Claim), REF02 (WSI Claim Number)

Allowed Values32 characters
Notes
Field Name

Insured Group Name

DescriptionRefers to the name of the insurance group or plan associated with the insured individual, aiding in accurate identification and claims processing.
Paper Claim Block61
Required / SituationalSituational
XML / JSON Fieldins_plan
X12 Loop / Segment2000B - SBR04
Allowed Values30 characters
Notes
Field Name

Insured Group Number

DescriptionThis is used to report the "Insured's Group Number," which refers to the specific identification number assigned to the insurance group or plan associated with the insured individual, aiding in accurate identification and claims processing.
Paper Claim Block62
Required / SituationalSituational
XML / JSON Fieldins_group
X12 Loop / Segment2000B - SBR03
Allowed Values30 characters
Notes
Field Name

Payer Address 1, Payer Address 2

DescriptionThis refers to the physical location where the insurance company or payer is located, crucial for accurate communication, billing, and claims processing in healthcare.
Paper Claim BlockUnder block 58 when "Show Payer Address" is checked
Required / SituationalSituational
XML / JSON Fieldpayer_addr_1, payer_addr_2
X12 Loop / SegmentN/A
Allowed Values55 characters
Notes
Field Name

Payer City

DescriptionThis is where the insurance company or payer is located, providing essential location information for accurate communication, billing, and claims processing in healthcare.
Paper Claim BlockN/A
Required / SituationalSituational
XML / JSON Fieldpayer_city
X12 Loop / SegmentN/A
Allowed Values30 characters
Notes
Field Name

Payer State

DescriptionThis is the state where the insurance company or payer is located, playing a vital role in accurate communication, geographic identification, billing, and claims processing in healthcare.
Paper Claim BlockUnder block 58 when "Show Payer Address" is checked
Required / SituationalSituational
XML / JSON Fieldpayer_state
X12 Loop / SegmentN/A
Allowed Values2 characters
Notes
Field Name

Payer Zip

DescriptionThis refers to the postal code associated with the location of the insurance company or payer, which is crucial for precise communication, geographic identification, billing, and claims processing in the healthcare industry.
Paper Claim BlockUnder block 58 when "Show Payer Address" is checked
Required / SituationalSituational
XML / JSON Fieldpayer_zip
X12 Loop / SegmentN/A
Allowed Values15 characters
Notes
Field Name

Payer Country

DescriptionThis represents the internationally recognized two-letter code that identifies the specific country associated with the payer's location, enabling accurate geographical referencing for communication, billing, and claims processing in the healthcare context.
Paper Claim BlockUnder block 58 when "Show Payer Address" is checked
Required / SituationalSituational
XML / JSON Fieldpay_country
X12 Loop / SegmentN/A
Allowed Values2 characters
Notes


Facility Claim- Block 63-73
Treatment Authorization Code, Document Control Number, DX & POA Information
Field Name

Treatment Authorization Code

DescriptionThis is a unique identifier assigned to authorize and track specific healthcare services or treatments, ensuring proper communication, documentation, and claims processing between healthcare providers and payers.
Paper Claim Block63
Required / SituationalSituational
XML / JSON Fieldauth_code_1
X12 Loop / Segment2300 - REF01 (Value D9 – Document Control Number), REF02 (Unique Document Number)
Allowed Values32 characters
Notes
Field Name

Document Control Number (ICN/DCN)

DescriptionThis is a unique identifier assigned to a specific document, such as a claim or medical record, to facilitate organization, tracking, and reference, aiding in efficient document management and accurate healthcare processes.
Paper Claim Block64
Required / SituationalSituational
XML / JSON Fieldicn_dcn_1
X12 Loop / Segment2300 - REF01 (Value D9 – Document Control Number), REF02 (Unique Document Number)
Allowed Values32 characters
Notes
Field Name

Employer Name

DescriptionThis represents the internationally recognized two-letter code that identifies the specific country associated with the payer's location, enabling accurate geographical referencing for communication, billing, and claims processing in the healthcare context.
Paper Claim BlockUnder block 58 when "Show Payer Address" is checked
Required / SituationalSituational
XML / JSON Fieldins_employer
X12 Loop / Segment2010BA - NM101 (Value IL – Insured), NM102 (Value 2 – Organization), NM103 (Organization)
Allowed Values32 characters
Notes
Field NameDiagnosis Code Qualifier A-L, Present on Admission A-L
Description"Diagnosis Code Qualifier" refers to a code that indicates the type of diagnosis code being reported, such as "ICD" for International Classification of Diseases, aiding in accurate identification and categorization of medical conditions for billing and claims processing in healthcare.
"Principal Diagnosis Code and Present on Admission (POA) Indicator" involves reporting the primary diagnosis code for the patient's condition along with an indicator that specifies whether the condition was present upon admission to the healthcare facility, crucial for accurate billing and claims processing, and assessment of hospital-acquired conditions.
Paper Claim Block66 and 67
Required / SituationalSituational
XML / JSON Fielddiag_1, diag_2, diag_3, diag_4, diag_5, diag_6, diag_7, diag_8, diag_9, diag_10, diag_11, diag_12
diag_1_poa, diag_2_poa, diag_3_poa, diag_4_poa, diag_5_poa, diag_6_poa, diag_7_poa, diag_8_poa, diag_9_poa, diag_10_poa, diag_11_poa, diag_12_poa
X12 Loop / SegmentLoop 2300+ HI01-1 (Value ABK - ICD10)
Loop 2300 HI01-1 (Value ABK – ICD10), HI01-2 (Code), HI01-9 (Value Y – Yes, N – No, U – Unknown, or W – Not Applicable)
Allowed Values8 characters (diagnosis code qualifier)
1 character (Y/N)
Notes

Field does not exist in Claim.MD form

Field Name

Reserved for Assignment by the NUBC

DescriptionN/A
Paper Claim Block68
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / SegmentN/A
Allowed ValuesN/A
Notes
Field Name

Admitting Diagnosis Code

Description"Admitting Diagnosis Code" is a medical code used to identify the primary reason for a patient's admission to a healthcare facility, aiding in accurate classification, documentation, and claims processing for the patient's condition.
Paper Claim Block69
Required / SituationalSituational
XML / JSON Fieldadmit_diag -HI01-1 (Value ABJ – ICD10), HI01-2 (Code)
X12 Loop / Segment2300
Allowed ValuesN/A
Notes


Field does not exist in Claim.MD form

Field Name

Patient Reason Code

Description"Patient Reason Code" is a code used to indicate the patient's specific reason for seeking medical care or undergoing a healthcare service, aiding in accurate documentation and claims processing. It provides additional context about the patient's condition or situation that led to the need for medical attention.
Paper Claim Block70
Required / SituationalSituational
XML / JSON Fielddiag_1, diag_2, diag_3, diag_4, diag_5, diag_6, diag_7, diag_8, diag_9, diag_10, diag_11, diag_12
diag_1_poa, diag_2_poa, diag_3_poa, diag_4_poa, diag_5_poa, diag_6_poa, diag_7_poa, diag_8_poa, diag_9_poa, diag_10_poa, diag_11_poa, diag_12_poa
X12 Loop / SegmentLoop 2300 - HI01-1 (Value APR – ICD10) HI01-2 (Code)
Allowed Values8 characters (diagnosis code qualifier)
1 character (Y/N)
Notes
Field Name

Diagnosis Related Group Number

Description"Diagnosis-Related Group (DRG) Number" is a code used to categorize and group together patients with similar clinical conditions who require similar levels of hospital resources. DRG codes are used for billing and reimbursement purposes, helping healthcare facilities receive appropriate payment based on the complexity and severity of cases they treat.
Paper Claim Block71
Required / SituationalSituational
XML / JSON Field

drg

X12 Loop / Segment

HI01-1 (Value DR – Diagnosis Related Group, HI01-2 (MS-DRG)

Allowed Values3 characters
Notes
Field Name

External Injury Code 1-3, External Injury Present on Admission 1-

Description"Diagnosis Code Qualifier" refers to a code that indicates the type of diagnosis code being reported, such as "ICD" for International Classification of Diseases, aiding in accurate identification and categorization of medical conditions for billing and claims processing in healthcare.
"Principal Diagnosis Code and Present on Admission (POA) Indicator" involves reporting the primary diagnosis code for the patient's condition along with an indicator that specifies whether the condition was present upon admission to the healthcare facility, crucial for accurate billing and claims processing, and assessment of hospital-acquired conditions.
Paper Claim Block72a-c
Required / SituationalSituational
XML / JSON Field2300 - HI01-1 (Value DR – Diagnosis Related, HI01-2 (MS-DRG)
X12 Loop / Segmente_code, e_code_2, e_code_3
e_code_1_poa, e_code_2_poa, e_code_3_poa
Allowed Values8 characters (diagnosis code qualifier)
1 character (Y/N)
Notes

Field does not exist in Claim.MD form

Field Name

Reserved for Assignment by the NUBC

DescriptionN/A
Paper Claim Block73
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / SegmentN/A
Allowed ValuesN/A
Notes
Facility Claim- Block 74-75
Principal Procedure
Field Name

Principal Procedure Code and Date (The ICD-9-CM for Principal Procedure)

DescriptionRefers to reporting the primary medical procedure or surgical intervention code along with the date it was performed during a patient's hospital stay, aiding in accurate billing, claims processing, and documentation of the significant medical action related to the primary diagnosis.
Paper Claim Block74
Required / SituationalSituational
XML / JSON Fieldproc_clmcode_1, proc_date_1_date
X12 Loop / SegmentLoop 2300 -  HI01-1 (Value BBR– ICD10), HI01-2 (Code), HI01-3 (Value D8 – Format: , CCYYMMDD), HI01-4 (Date Performed)
Allowed Values

Text 8 (code)
Date yyyymmdd (date)

Notes
Field Name

Other Procedure and Date a-e

Descriptioninvolves reporting additional medical procedure or surgical intervention codes along with their corresponding dates of performance during a patient's hospital stay, ensuring accurate billing, claims processing, and proper documentation of supplementary medical actions.
Paper Claim Block74a-e
Required / SituationalSituational
XML / JSON Fieldproc_clmcode_2, proc_clmcode_3, proc_clmcode_4, proc_clmcode_5, proc_clmcode_6
X12 Loop / Segment2300 - HI01-1 (Value BBR, HI01-2 (Code), HI01-3 (Value D8 – Format: CCYYMMDD), HI01-4 (Date Performed)
Allowed ValuesText 8 (code)
Date yyyymmdd (date)
Notes

Field does not exist in Claim.MD form

Field Name

Reserved for Assignment by the NUBC

DescriptionN/A
Paper Claim Block75
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / SegmentN/A
Allowed ValuesN/A
Notes


Facility Claim- Block 76-79
Attending, Operating, Other Physician Information


Field Name

Attending Provider Name (Last, First, Middle)

DescriptionRefers to the full name of the healthcare provider who is primarily responsible for overseeing and directing the patient's care during their hospital stay, aiding in accurate identification, communication, and claims processing.
Paper Claim Block76
Required / SituationalSituational
XML / JSON Fieldprov_name_l, prov_name_f, prov_name_m
X12 Loop / Segment2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code)
Allowed Values35 characters, 25 characters, 25 characters
Notes
Field Name

Attending Provider NPI and Provider ID

DescriptionThese are both unique identifiers used to distinguish healthcare providers. The NPI is a standardized numeric code assigned to individual healthcare providers or organizations, while the Provider ID is a specific identifier assigned by a healthcare facility or insurer to a provider within their network. These identifiers play a crucial role in accurate communication, billing, and claims processing in the healthcare industry.
Paper Claim Block76
Required / SituationalSituational
XML / JSON Fieldprov_npi, prov_id
X12 Loop / Segment2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code)
Allowed ValuesNumeric 10, 32 characters
Notes
Field Name

Attending Provider Taxonomy

DescriptionThis refers to the specific Healthcare Provider Taxonomy Code that classifies the professional specialty or area of expertise of the attending healthcare provider overseeing a patient's care during their hospital stay, aiding in accurate categorization, communication, billing, and claims processing.
Paper Claim Block76
Required / SituationalSituational
XML / JSON Fieldprov_taxonomy
X12 Loop / Segment2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code)
Allowed Values10 characters
Notes
Field Name

Operating Provider Name (Last, First, Middle)

DescriptionThis is the full name of the healthcare professional who performs the primary procedure or surgery on a patient during a hospital stay, aiding in accurate identification, communication, billing, claims processing, and documentation of the responsible provider for the performed medical intervention.
Paper Claim Block77
Required / SituationalSituational
XML / JSON Field2310A -NM101 (Value 72 – Operating Provider)NM102 (Value 1 – Person), NM103 (Last NameNM104 (First Name), NM105 (Middle Name), NM108 (ValueXX), NM109 (NPI)PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code)
X12 Loop / Segmentprov2_name_l, prov2_name_f, prov2_name_m
Allowed Values32 characters (last), 32 characters (first), 1 character (middle)
Notes
Field Name

Operating Provider NPI and Provider ID

DescriptionThis is the unique National Provider Identifier for the healthcare professional performing a primary procedure or surgery, and "Operating Provider ID" is the facility-assigned identifier, both vital for precise communication, billing, and claims processing.
Paper Claim Block77
Required / SituationalSituational
XML / JSON Fieldprov2_npi, prov2_id
X12 Loop / Segment2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code)
Allowed ValuesNumeric 10, 32 characters
Notes
Field Name

Operating Provider Taxonomy

DescriptionThis refers to the specific Healthcare Provider Taxonomy Code that classifies the professional specialty or area of expertise of the healthcare provider performing the primary procedure or surgery during a patient's hospital stay, aiding in accurate categorization, communication, billing, and claims processing.
Paper Claim Block77
Required / SituationalSituational
XML / JSON Fieldprov2_taxonomy
X12 Loop / Segment2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code)
Allowed Values10 characters
Notes
Field Name

Other Provider Name (Last, First, Middle)

DescriptionRefers to the full name of a healthcare provider, other than the attending or operating provider, who played a role in the patient's care during their hospital stay, aiding in accurate identification, communication, billing, claims processing, and documentation of all involved providers.
Paper Claim Block78 (and 79)
Required / SituationalSituational
XML / JSON Field2310C, 2310D, 2310F - NM101 (Value DN – Referring Provider, ZZ – Other Operating Provider, or 82 – Rendering Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC - Taxonomy), PRV03 (Taxonomy Code)
X12 Loop / Segmentprov3_name_l, prov3_name_f, prov3_name_m
Allowed Values32 characters (last), 32 characters (first), 1 character (middle)
Notes
Field Name

Other Provider NPI and Provider ID

DescriptionThis is the National Provider Identifier for a healthcare provider, not the attending or operating provider, involved in the patient's care, and "Other Provider ID" is the facility-assigned identifier for the same provider, both essential for precise communication, billing, and claims processing.
Paper Claim Block78  (and 79)
Required / SituationalSituational
XML / JSON Fieldprov3_npi, prov3_id
X12 Loop / Segment2310C, 2310D, 2310F - NM101 (Value DN – Referring Provider, ZZ – Other Operating Provider, or 82 – Rendering Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC - Taxonomy), PRV03 (Taxonomy Code)
Allowed ValuesNumeric 10, 32 characters
Notes
Field Name

Other Provider Taxonomy

DescriptionThis refers to the specific Healthcare Provider Taxonomy Code that classifies the professional specialty or area of expertise of the healthcare provider performing the primary procedure or surgery during a patient's hospital stay, aiding in accurate categorization, communication, billing, and claims processing.
Paper Claim Block78  (and 79)
Required / SituationalSituational
XML / JSON Fieldprov3_taxonomy
X12 Loop / Segment2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code)
Allowed Values10 characters
Notes
Field Name

Referring Provider Name (Last, First, Middle)

DescriptionRefers to the full name of the healthcare provider who recommended or referred the patient for a hospital stay or specific medical services, aiding in accurate identification, communication, billing, claims processing, and documentation of the provider's role in the patient's care.
Paper Claim Block78  (and 79)
Required / SituationalSituational
XML / JSON Field2310C, 2310D, 2310F - NM101 (Value DN – Referring Provider, ZZ – Other Operating Provider, or 82 – Rendering Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC - Taxonomy), PRV03 (Taxonomy Code)
X12 Loop / Segmentref_name_l, ref_name_f, ref_name_m
Allowed Values35 characters (last), 25 characters (first), 25 character (middle)
Notes
Field Name

Referring Provider NPI and Provider ID

DescriptionThis is the National Provider Identifier for the healthcare provider who recommended or referred the patient, and "Referring Provider ID" is the facility-assigned identifier for the same provider, both essential for precise communication, billing, and claims processing.
Paper Claim Block78  (and 79)
Required / SituationalSituational
XML / JSON Fieldref_npi, ref_id
X12 Loop / Segment2310C, 2310D, 2310F - NM101 (Value DN – Referring Provider, ZZ – Other Operating Provider, or 82 – Rendering Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC - Taxonomy), PRV03 (Taxonomy Code)
Allowed ValuesNumeric 10, 32 characters
Notes
Field Name

Rendering Provider Name (Last, First, Middle)

DescriptionRefers to the full name of the healthcare provider who performed the medical services or procedures for the patient, aiding in accurate identification, communication, billing, claims processing, and documentation of the provider responsible for the provided healthcare services.
Paper Claim Block78  (and 79)
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / SegmentN/A
Allowed Values35 characters (last), 25 characters (first), 25 character (middle)
Notes
Field Name

Rendering Provider NPI and Provider ID

DescriptionThis is the National Provider Identifier for the healthcare provider who performed the medical services or procedures, and "Rendering Provider ID" is the facility-assigned identifier for the same provider, both crucial for precise communication, billing, and claims processing.
Paper Claim Block78  (and 79)
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / SegmentN/A
Allowed ValuesNumeric 10, 32 characters
Notes


Facility Claim- Block 80-81
Remarks
Field Name

Remarks

DescriptionThis field provides space for additional notes or comments that healthcare providers may wish to include regarding the patient's condition, treatment, or any other relevant information. This section allows for supplementary details that could aid in accurate billing, claims processing, or provide context for the patient's care.
Paper Claim Block80
Required / SituationalSituational
XML / JSON FieldN/A
X12 Loop / SegmentLoop 2300 - NTE01 (Value ADD), NTE02 (Notes)
Allowed Values80 characters
NotesNote that the field can be enlarged for longer comments by clicking and dragging the right corner


Field not displayed on Claim.MD form

Field Name

81a-d Code-Code

DescriptionRefers to the codes used to specify the type of healthcare facility and specific accommodation or room category where the patient received treatment during their hospital stay. These codes help categorize and communicate details about the patient's accommodations for accurate billing, claims processing, and documentation.

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