The electronic form used in modern healthcare billing is based on the HCFA 1500 paper form, also known as the CMS-1500 form. The Claim.MD online version of this form retains the familiarity of the standard paper form but allows for additional electronic elements supported in the 837P electronic claim standard. This document gives a description of each field on the claim form and a crosswalk to their associated electronic elements.
The paper version of the claim form (HCFA 1500) can be visually compared to identify the differences. For instance, on the paper claim form, the patient/authorized person's signature is placed in Block 12, while the insured/authorized signature is in Block 13. However, these blocks are not present in the electronic Claim.MD version.
This crosswalk serves as a reference, and much of the data used in the X12 ANSI format is derived from the content presented on the website.
Claim.MD Professional Claim Form (as seen in View/Edit Claim page)
Professional Claim- Block 1
Payer Information
| Field Name | Payer Name |
|---|
|
| Description | The name of the insurance payer or health plan. |
| Paper Claim Block | 1 |
| Required / Situational | Required |
| XML / JSON Field | payer_name |
| X12 Loop / Segment | Loop 2010BB / NM103 |
| Allowed Values | 64 characters |
| Notes | Information 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 | Payer ID |
|---|
|
| Description | The unique identifier for the primary payer. |
| Paper Claim Block | 1 |
| Required / Situational | Required |
| XML / JSON Field | payerid |
| X12 Loop / Segment | Loop 2000B / SBR09 |
| Allowed Values | 32 characters |
| Notes | Information 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 | Payer Address |
|---|
|
| Description | The address of the insurance payer or health plan. |
| Paper Claim Block | 1 |
| Required / Situational | Situational |
| XML / JSON Field | payer_addr_1 |
| X12 Loop / Segment | Loop 2010BB / N301 |
| Allowed Values | 55 characters |
| Notes | Information obtained from insurance card or directly from insurance provider.
Payer address is not required on electronic claims. |
| Field Name | Payer Address 2 |
|---|
|
| Description | Additional address line of the insurance payer or health plan. |
| Paper Claim Block | 1 |
| Required / Situational | Situational |
| XML / JSON Field | payer_addr_2 |
| X12 Loop / Segment | Loop 2010BB / N302 |
| Allowed Values | 55 characters |
| Notes | Information 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. Create a support ticket if a payer is not on the list. |
| Field Name | Payer City |
|---|
|
| Description | The name of the insurance payer or health plan. |
| Paper Claim Block | 1 |
| Required / Situational | Situational |
| XML / JSON Field | payer_city |
| X12 Loop / Segment | Loop 2010BB / N401 |
| Allowed Values | 30 characters |
| Notes | Information 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. Create a support ticket if a payer is not on the list. |
| Field Name | Payer State |
|---|
|
| Description | The state where the insurance payer or health plan is located. |
| Paper Claim Block | 1 |
| Required / Situational | Situational |
| XML / JSON Field | payer_state |
| X12 Loop / Segment | Loop 2010BB / N402 |
| Allowed Values | 2 characters |
| Notes | Information 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. Create a support ticket if a payer is not on the list. |
| Field Name | Payer Zip Code |
|---|
|
| Description | The ZIP code of the insurance payer or health plan. |
| Paper Claim Block | 1 |
| Required / Situational | Situational |
| XML / JSON Field | payer_zip |
| X12 Loop / Segment | Loop 2010BB / N403 |
| Allowed Values | 15 characters |
| Notes |
|
| Field Name | Insured I.D. Number |
|---|
|
| Description | The identification number of the insured individual. |
| Paper Claim Block | 1a |
| Required / Situational | Required |
| XML / JSON Field | ins_number |
| X12 Loop / Segment | Loop 2010BA / NM109 |
| Allowed Values | 32 characters |
| Notes | Provide the insured's ID number exactly as it appears on their ID card for the payer to whom the claim is being submitted. In case the patient has a specific Member Identification Number assigned by the payer, please enter that number in this field. |
Professional Claim- Block 2-4
Patient Information
| Field Name | Patient Name |
|---|
|
| Description | The full last name, first name, and middle initial of the patient receiving the medical services. |
| Paper Claim Block | 2 |
| Required / Situational | Required (except for middle initial) |
| XML / JSON Field: | pat_name_l, pat_name_f, pat_name_m |
| X12 Loop / Segment | Loop 2010BA / NM103 / NM104 / NM105 |
| Allowed Values | 35 characters (last name) / 25 characters (first name) / 25 characters (middle initial) |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Patient Date of Birth |
|---|
|
| Fieldname | Patient Date of Birth |
| Description | The date of birth of the patient. |
| Paper Claim Block | 3 |
| Required / Situational | Required |
| XML / JSON Field | pat_dob |
| X12 Loop / Segment | Loop 2010BA / DMG02 |
| Allowed Values | 10 characters, Date format (MM-DD-YYYY) |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Patient Sex |
|---|
|
| Description | The sex of the patient. |
| Paper Claim Block | 2 |
| Required / Situational | Required |
| XML / JSON Field | patient_sex |
| X12 Loop / Segment | Loop 2010BA / DMG03 |
| Allowed Values | 1 character - M (Male), F (Female), U (Unknown) |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Insured's Name |
|---|
|
| Description | The full last name, full first name, middle initial of insured individual. The insured individual is the person who holds the policy. |
| Paper Claim Block | 4 |
| Required / Situational | Situational |
| XML / JSON Field | ins_name_l, ins_name_f, ins_name_m |
| X12 Loop / Segment | Loop 2010BA / NM103, NM104, NM105, NM107 |
| Allowed Values | 35 characters (last name) / 25 characters (first name) / 25 characters (middle initial) |
| Note | Information usually obtained from insurance card. |
Professional Claim- Block 5-8
Patient Information / Insured's Information
| Field Name | Patient Address |
|---|
|
| Description | The first line of the patient's address. |
| Paper Claim Block | 5 |
| Required / Situational | Required |
| XML / JSON Field | ins_addr_1 |
| X12 Loop / Segment | Loop 2010CA / N301 |
| Allowed Values | 55 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Patient Address 2 |
|---|
|
| Description | The second line of the patient's address (if applicable). |
| Paper Claim Block | 5 |
| Required / Situational | Situational |
| XML / JSON Field | ins_addr_2 |
| X12 Loop / Segment | Loop 2010CA / N302 |
| Allowed Values | 55 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Patient City |
|---|
|
| Description | The city where the patient resides. |
| Paper Claim Block | 5 |
| Required / Situational | Required |
| XML / JSON Field | pat_city |
| X12 Loop / Segment | Loop 2010CA / N401 |
| Allowed Values | 30 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Patient State |
|---|
|
| Description | The state where the patient resides. |
| Paper Claim Block | 5 |
| Required / Situational | Required |
| XML / JSON Field | pat_state |
| X12 Loop / Segment | Loop 2010CA / N402 |
| Allowed Values | 2 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Patient Zip Code |
|---|
|
| Description | The ZIP code of the patient's address. |
| Paper Claim Block | 5 |
| Required / Situational | Required |
| XML / JSON Field | pat_zip |
| X12 Loop / Segment | Loop 2010CA / N403 |
| Allowed Values | 15 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Patient Country Code |
|---|
|
|
| Description | The country code of the patient's address (if applicable). |
| Paper Claim Block | 5 |
| Required / Situational | Situational |
| XML / JSON Field | pat_country |
| X12 Loop / Segment | Loop 2010CA - N4 |
| Allowed Values | 2 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Patient Phone Number |
|---|
|
| Description | The phone number of the patient. |
| Paper Claim Block | 5 |
Required / Situational: Situational | Situational |
| XML / JSON Field: | pat_phone |
| X12 Loop / Segment | Loop 2010CA - PER |
| Allowed Values | 10 characters |
| Note | *Not on Claim.MD form. Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Patient Relationship |
|---|
|
Description
| The relationship of the patient to the insured individual.
|
Paper Claim Block
| 6
|
Required / Situational
| Required
|
XML / JSON Field
| pat_rel |
X12 Loop / Segment
| Loop 2000B / 2000C - SBR02 / PAT01
|
Allowed Values
| 2 characters - codes representing patient relationships to insured (e.g., 18 for Self, 01 for Spouse, 19 for Child)
|
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Insured's Address |
|---|
|
Description
| The first line of the insured individual's address.
|
Paper Claim Block
| 7
|
Required / Situational
| Situational
|
XML / JSON Field
| <insured_address_1>
|
| X12 Loop / SegmentX12 Loop / Segment | 2010BA - N301
|
Allowed Values
| 55 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
|
| Field Name | Insured's Address 2 |
|---|
|
Description
| The second line of the insured individual's address (if applicable). |
Paper Claim Block | 7 |
Required / Situational
| Situational
|
| XML / JSON Field | ins_addr_2 |
X12 Loop / Segment
| Loop 2010BA - N302
|
Allowed Values
| 55 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
|
| Field Name | Insured's City |
|---|
|
Description
| The city where the insured individual resides.
|
Paper Claim Block
| 7
|
Required / Situational
| Situational
|
XML / JSON Field
| ins_city |
X12 Loop / Segment
| Loop 2010BA - N401
|
Allowed Values
| 30 characters
|
Note
| Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
|
| Field Name | Insured's State |
|---|
|
Description
| The state where the insured individual resides. |
Paper Claim Block
| 7
|
Required / Situational
| Situational
|
XML / JSON Field
| ins_state
|
X12 Loop / Segment
| 2010BA - N42010BA - N402
|
Allowed Values
| 2 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
|
| Field Name | Insured Zip |
|---|
|
Description
| The ZIP code of the insured individual's address. |
Paper Claim Block
| 7 |
| Required / Situational | Situational |
XML / JSON Field
| ins_zip
|
X12 Loop / Segment
| 2010BA - N403
|
Allowed Values
| 15 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Insured Country Code |
|---|
|
Description
| The country code of the insured individual's address (if applicable).
|
Paper Claim Block
| 7
|
| Required / Situational | Situational
|
XML / JSON Field
| ins_country
|
X12 Loop / Segment
| Loop 2010BA - N4
|
Allowed Values
| 2 characters |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
|
Field not visible on claim form
| Field Name | Insured Phone Number |
|---|
|
| Description | The phone number of the insured individual. |
| Paper Claim Block | 7 |
| Required / Situational | Situational |
| XML / JSON Field | ins_phone |
| X12 Loop / Segment | Loop 2010BA - PER |
| Allowed Values | 10 characters |
| Note | Not on electronic form. Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Field Name | Marital and Work Status |
|---|
|
Description
| This field indicates the marital status and work status of the patient, providing information about their marital relationship and current employment status.
|
Paper Claim Block
| 8
|
Required / Situational
| Situational |
| XML / JSON Field | pat_marital
|
| X12 Loop / Segment | Patient Status does not exist in the 837P |
| Allowed Values | 1 character Y/N - Marital (Single, Married, Other); Employment (Employed, Full-time student, Part-time student) |
| Note | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc |
Professional Claim- Block 9
Secondary Insured's Information / Medicare Type Code
| Fieldname | Secondary Insured Last Name |
|---|
|
| Description | The last name or surname of the insured individual for other insurance. |
| Paper Claim Block | 9 |
| Required / Situational | Situational |
| XML / JSON Field | other_ins_name_l |
| X12 Loop / Segment | Loop 2330A- NM103 (Name) |
| Allowed Values | 35 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Insured First Name |
|---|
|
| Description | The last name or surname of the insured individual for other insurance. |
| Paper Claim Block | 9 |
| Required / Situational | Situational |
| XML / JSON Field | other_ins_name_f |
| X12 Loop / Segment | Loop 2330A- NM104 (Name) |
| Allowed Values | 35 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Insured's Middle Name |
|---|
|
| Description | The middle name or initial of the insured individual for other insurance. |
| Paper Claim Block | 9 |
| Required / Situational | Situational |
| XML / JSON Field: | other_ins_name_m |
| X12 Loop / Segment | Loop 2330A - NM105 |
| Allowed Values | 25 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Insured's Policy Number |
|---|
|
| Description | The policy number associated with the other insurance coverage. |
| Paper Claim Block | 9a |
| Required / Situational | Situational |
| XML / JSON Field | other_ins_number |
| X12 Loop / Segment | Loop 2320 - SBR03 |
| Allowed Values | 32 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Insured's Date of Birth |
|---|
|
| Description | The date of birth of the insured individual for other insurance. |
| Paper Claim Block | 9b (this field is typically not part of the standard CMS-1500 (02/12) paper claim form.) |
| Required / Situational | Situational |
| XML / JSON Field | other_ins_dob |
| X12 Loop / Segment | Loop 2320B- DMG02 |
| Allowed Values | Date format (yyyymmdd) |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Insured's Sex |
|---|
|
| Description | The gender or sex of the insured individual for other insurance. |
| Paper Claim Block | 9b (this field is typically not part of the standard CMS-1500 (02/12) paper claim form.) |
| Required / Situational | Situational |
| XML / JSON Field | other_ins_sex |
| X12 Loop / Segment | Loop 2320B - DMG03 |
| Allowed Values | 2 characters - M (Male), F (Female), U (Unknown), or other valid gender codes. |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Payment Date |
|---|
|
| Description | The "Primary Payment Date" refers to the date when the primary insurance payer made the payment for the healthcare services rendered. |
| Paper Claim Block | 9c (this field is not part of the standard CMS-1500 (02/12) paper claim form.) |
| Required / Situational | N/A (Not applicable as this field is not included in the standard CMS-1500 (02/12) paper claim form.) |
| XML / JSON Field | other_ins_payment_date |
| X12 Loop / Segment | Loop 2330B / Segment DTP / Qualifier 573 |
| Allowed Values | Date yyyymmdd |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Payer's Name |
|---|
|
| Description | The name of the other insurance payer or health plan that is responsible for processing the claim as a secondary or tertiary payer. |
| Paper Claim Block | 9d |
| Required / Situational | Situational |
| XML / JSON Field | other_payer_name |
| X12 Loop / Segment | Loop 2320 - SBR04 OI |
| Allowed Values | 32 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Insurance Payer ID |
|---|
|
| Description | The identification number of the insurance payer for other insurance. |
| Paper Claim Block | 9d |
| Required / Situational | Situational |
| XML / JSON Field | other_payerid |
| X12 Loop / Segment | Loop 2320 - REF01 |
| Allowed Values | 8 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Payer Filing Code (Medicare Type Code) |
|---|
|
| Description | A code identifying the secondary insurance responsible for payment after the primary payer. It ensures accurate billing and proper claim processing by indicating the order of payer responsibility.
|
| Paper Claim Block | 9d |
| Required / Situational | Situational |
| XML / JSON Field | other_claimfilingcode
|
| X12 Loop / Segment | Loop 2320 - SBR09 |
| Allowed Values | Text 2. Example (12- Working Age, 43- Medicare Disabled, etc.). |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Payer's Claim ID |
|---|
|
| Description | The unique identification number assigned to the claim by the other insurance payer. |
| Paper Claim Block | 9d |
| Required / Situational | Situational |
| XML / JSON Field | other_payerid |
| X12 Loop / Segment | Loop 2320 - REF02 |
| Allowed Values | Allowed Values |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Payer Address 1 |
|---|
|
| Description | The first line of the address of the other insurance payer. |
| Paper Claim Block | 9d |
| Required / Situational | Situational |
| XML / JSON Field | other_payer_addr_1 |
| X12 Loop / Segment | Loop 2320 / N301 |
| Allowed Values | 55 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Payer Address 2 |
|---|
|
| Description | The second line of the address of the other insurance payer. |
| Paper Claim Block | 9d |
| Required / Situational | Situational |
| XML / JSON Field | other_payer_addr_2 |
| X12 Loop / Segment | Loop 2320 / N302 |
| Allowed Values | 55 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Payer City |
|---|
|
| Description | The city where the other insurance payer is located. |
| Paper Claim Block | 9d |
| Required / Situational | Situational |
| XML / JSON Field | other_payer_city |
| X12 Loop / Segment | Loop 2320 / N401 |
| Allowed Values | 2 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Payer State |
|---|
|
| Description | The state where the other insurance payer is located. |
| Paper Claim Block | 9d |
| Required / Situational | Situational |
| XML / JSON Field | other_payer_state |
| X12 Loop / Segment | Loop 2320 / N402 |
| Allowed Values | Two-letter state abbreviation. |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Payer Zip |
|---|
|
| Description | The ZIP code of the other insurance payer's location. |
| Paper Claim Block | 9d |
| Required / Situational | Situational |
| XML / JSON Field | other_payer_zip |
| X12 Loop / Segment | Loop 2320 / N403 |
| Allowed Values | 15 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Medicare Type Code |
|---|
|
| Description | The Medicare Type Code indicates the type of Medicare program or plan under which the patient is covered. |
| Paper Claim Block | 9d |
| Required / Situational | Situational |
| XML / JSON Field | other_ins_medicare_code |
| X12 Loop / Segment | Loop 2300 / EB04 |
| Allowed Values | 2 characters |
| Note | The Medicare Type Code is specific to Medicare claims and may not be applicable to other insurance payers. It is used to indicate the type of Medicare coverage for the patient's claim |
| Fieldname | Secondary Policy Relationship |
|---|
|
| Description | The relationship of the insured to the policyholder or primary beneficiary of the other insurance policy. |
| Paper Claim Block | 9e |
| Required / Situational | Situational |
| XML / JSON Field | other_pat_rel |
| X12 Loop / Segment | Loop 2320B / SBR02 |
| Allowed Values | 2 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Policy Group Name |
|---|
|
| Description | The name of the group or employer providing the other insurance coverage, if applicable. |
| Paper Claim Block | 9f |
| Required / Situational | Situational |
| XML / JSON Field | other_ins_group |
| X12 Loop / Segment | Loop 2320B - REF02 |
| Allowed Values | 30 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Secondary Policy Number |
|---|
|
| Description | The identification number or code of the other insurance policy covering the patient's healthcare services. |
| Paper Claim Block | 9g |
| Required / Situational | Situational |
| XML / JSON Field | other_ins_number |
| X12 Loop / Segment | Loop 2320B - REF01 |
| Allowed Values | 30 characters |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
Professional Claim- Block 10
Accident / Auto Related
| Fieldname | Accident Related to Employment |
|---|
|
| Description | Indicates whether the accident is related to employment. |
| Paper Claim Block | 10a |
| Required / Situational | Situational |
| XML / JSON Field | employment_related |
| X12 Loop / Segment | Loop 2300 - CLM11 PWK |
| Allowed Values | 1 character - Y (Yes), N (No) |
| Notes |
|
| Fieldname | Accident Related to Auto |
|---|
|
| Description | Indicates whether the accident is related to an automobile accident. |
| Paper Claim Block | 10b |
| Required / Situational | Situational |
| XML / JSON Field | auto_accident |
| X12 Loop / Segment | Loop 2300 - CLM11 PWK |
| Allowed Values | 1 character - Y (Yes), N (No) |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Auto Accident State |
|---|
|
| Description | The state where the auto accident occurred. |
| Paper Claim Block | 10b |
| Required / Situational | Situational |
| XML / JSON Field | auto_accident_state |
| X12 Loop / Segment | Loop 2300 - CLM11 PWK (Claim Supplemental Information) |
| Allowed Values | Two-letter state abbreviation |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Other Accident Related |
|---|
|
| Description | Indicates whether the accident is related to another type of accident. |
| Paper Claim Block | 10c |
| Required / Situational | Situational |
| XML / JSON Field | other_accident |
| X12 Loop / Segment | Loop 2300 - CLM11 PWK |
| Allowed Values | 1 character - Y (Yes), N (No) |
| Notes | Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc. |
| Fieldname | Condition Code (1, 2, 3) |
|---|
|
| Description | Claim codes in field refer to the codes used to indicate specific conditions or reasons for the claim submission. These codes provide additional information related to the claim and may help in processing and adjudicating the claim accurately. |
| Paper Claim Block | 10d |
| Required / Situational | Situational |
| XML / JSON Field | cond_code_1, cond_code_2, cond_code_3 |
| X12 Loop / Segment | Loop 2300 - HI CLM |
| Allowed Values | 2 characters Common examples include:- "A0" - Medical Emergency
- "B3" - Change in Diagnosis or Misdiagnosis
- "B7" - Performed Prior to Authorization
- "P4" - Item Provided as a Preoperative Service Only
- "PR" - Patient Responsibility
- "PI" - Primary Insurance
- "OA" - Other Accident
- "NU" - New Equipment
- "GW" - Service Not Related to the Hospice Patient's Terminal Condition
- "ZA" - Medicare Blood Deductible
- "ZZ" - Mutually Defined
|
| Notes | The specific claim codes used may vary depending on the payer's guidelines and requirements. Providers should use appropriate and accurate claim codes to ensure proper processing and payment of the claim. |
Professional Claim- Block 11
Insured's Information
| Fieldname | Insured's Policy Group |
|---|
|
| Description | The group number associated with the insured individual's insurance plan. |
| Paper Claim Block | 11 |
| Required / Situational | Situational |
| XML / JSON Field | ins_group |
| X12 Loop / Segment | Loop 2000B - SBR03 REF |
| Allowed Values | 30 characters |
| Notes | Insurance Information |
| Fieldname | Insured Date of Birth |
|---|
|
| Description | The date of birth of the insured individual. |
| Paper Claim Block | 11a |
| Required / Situational | Situational |
| XML / JSON Field | ins_dob |
| X12 Loop / Segment | Loop 2010BA - DMG02 |
| Allowed Values | Date format yyyymmdd |
| Notes | Insurance Information |
| Fieldname | Insured Gender |
|---|
|
| Description | The gender of the insured individual. |
| Paper Claim Block | 11a |
| Required / Situational | Situational |
| XML / JSON Field | ins_sex |
| X12 Loop / Segment | Loop 2010BA - DMG03 |
| Allowed Values | 1 character - M (Male), F (Female), U (Unknown) |
| Notes | Insurance Information |
| Fieldname | Insured Employer Name/School Name/ Other Claim ID |
|---|
|
| Description | The name of the insured individual's employer. |
| Paper Claim Block | 11b |
| Required / Situational | Situational |
| XML / JSON Field | ins_employer |
| X12 Loop / Segment | Loop 2010BA - REF01, REF02 |
| Allowed Values | 32 characters |
| Notes | Insurance Information |
| Fieldname | Insured Plan Name |
|---|
|
| Description | The name of the insured individual's insurance plan. |
| Paper Claim Block | 11c |
| Required / Situational | Situational |
| XML / JSON Field | ins_plan |
| X12 Loop / Segment | Loop 2000B - SBR04 |
| Allowed Values | 30 characters |
| Notes | Insurance Information |
| Fieldname | Supervising Provider Name / ID / NPI |
|---|
|
| Description | The name of the supervisor or overseeing healthcare professional who provided or supervised the healthcare services. |
| Paper Claim Block | 2310D
|
| Required / Situational | Situational |
| XML / JSON Field | chg_supv_prov_name_l, chg_supv_prov_name_f, chg_supv_prov_name_m, chg_supv_prov_npi, chg_supv_prov_id |
| X12 Loop / Segment | N/A (Not applicable as this field is not part of the standard X12 EDI format for electronic claim submissions based on the CMS-1500 form.) |
| Allowed Values | 55 characters |
| Notes | Insurance Information |
Professional Claim- Block 14-19
Date of Condition, Referring Physician, Hospitalization dates, Claim Narrative,
More Information
Note that selecting an option from the ADD DATE field, will add a new date field under DATE OF CONDITION.
| Fieldname | Date of Condition / Date of Current illness, injury, pregnancy (LMP) |
|---|
|
| Description | The date when the current illness, injury, or pregnancy began. |
| Paper Claim Block | 14 |
| Required / Situational | Situational |
| XML / JSON Field | cond_date |
| X12 Loop / Segment | Loop 2300 - DTP01 / DTP03 |
| Allowed Values | Date yyyymmdd |
| Notes | Usually from PMS / EMR, medical notes, etc. |
| Fieldname | Date of Onset |
|---|
|
| Description | The date when the patient's symptoms or condition first started or when an injury occurred. |
| Paper Claim Block | 15 |
| Required / Situational | Situational |
| XML / JSON Field | onset_date |
| X12 Loop / Segment | Loop 2300 - DTP01, DTP03 |
| Allowed Values | Date yyyymmdd |
| Notes | Usually from PMS / EMR, medical notes, etc. |
| Fieldname | Date Last Seen |
|---|
|
| Description | The date when the patient was last seen for treatment or evaluation. |
| Paper Claim Block: | 15 |
| Required / Situational | Situational |
| XML / JSON Field | lastseen_date |
| X12 Loop / Segment | Loop 2300 - DTP01, DT03 |
| Allowed Values | Date format yyyymmdd |
| Notes | This field displays once Last Date Seen is selected in the Add Date dropdown.
Usually from PMS / EMR, medical notes, etc. |
| Fieldname | Unable to Work From Date |
|---|
|
| Description | The date when the patient became unable to work due to the reported condition or injury. |
| Paper Claim Block | 16 |
| Required / Situational | Situational |
| XML / JSON Field | nowork_from_date |
| X12 Loop / Segment | Loop 2300 - DTP03 |
| Allowed Values | Date yyyymmdd |
| Notes | Usually from PMS / EMR, medical notes, etc. |
| Fieldname | Unable to Work To Date |
|---|
|
| Description | The phrase "Unable to Work To Date" indicates that the individual has been unable to work up to the current date, implying a continuous period of being unable to work until the present moment. |
| Paper Claim Block | 16 |
| Required / Situational | Situational |
| XML / JSON Field | nowork_from_date |
| X12 Loop / Segment | Loop 2300 - DTP03 |
| Allowed Values | Date yyyymmdd |
| Notes | Usually from PMS / EMR, medical notes, etc. |
| Fieldname | Referring Provider Last Name |
|---|
|
| Description | The last name or surname of the referring provider. |
| Paper Claim Block | 17 |
| Required / Situational: | Situational |
| XML / JSON Field | ref_name_l |
| X12 Loop / Segment | Loop 2310A - NM101 |
| Allowed Values | 35 characters |
| Notes | Usually from PMS / EMR, medical notes, etc.
Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Referring Provider First Name |
|---|
|
| Description | The first name or given name of the referring provider. |
| Paper Claim Block | 17 |
| Required / Situational | Situational |
| XML / JSON Field | ref_name_f |
| X12 Loop / Segment | Loop 2310A - NM103 |
| Allowed Values | 25 characters |
| Notes | Usually from PMS / EMR, medical notes, etc.
Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Referring Provider Middle Name |
|---|
|
| Description | The middle name or initial of the referring provider. |
| Paper Claim Block | 17 |
| Required / Situational | Situational |
| XML / JSON Field: | ref_name_m |
| X12 Loop / Segment | Loop 2310A - NM104 |
| Allowed Values | 25 characters |
| Notes | Usually from PMS / EMR, medical notes, etc.
Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Referring Provider NPI |
|---|
|
| Description | The National Provider Identifier (NPI) of the referring provider. |
| Paper Claim Block | Block: 17a |
| Required / Situational | Situational |
| XML / JSON Field | ref_npi |
| X12 Loop / Segment | Loop 2310A - NM109 |
| Allowed Values | Numeric 10 characters |
| Notes | Usually from PMS / EMR, medical notes, etc.
Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Referring Provider Atypical ID |
|---|
|
| Description | The atypical ID associated with the referring provider, if applicable. |
| Paper Claim Block | 17b |
| Required / Situational | Situational |
| XML / JSON Field | ref_id |
| X12 Loop / Segment | Loop 2310A - REF01, REF02 |
| Allowed Values: | 32 characters |
| Notes | Usually from PMS / EMR, medical notes, etc.
Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Hospital Admit Date / Dates Related to Current Services |
|---|
|
| Description | The date when the patient was admitted to the hospital. |
| Paper Claim Block | 18 |
| Required / Situational | Situational |
| XML / JSON Field: | hosp_from_date |
| X12 Loop / Segment: | Loop 2300 - DTP03 |
| Allowed Values | Date yyyymmdd |
| Notes | Usually from PMS / EMR, medical notes, etc. |
| Fieldname | Hospital Discharge Date |
|---|
|
| Description | The date when the patient was discharged from the hospital. |
| Paper Claim Block | 18 |
| Required / Situational | Situational |
| XML / JSON Field | hosp_thru_date |
| X12 Loop / Segment | Loop 2300 - DTP03 |
| Allowed Values | Date yyyymmdd |
| Notes | Usually from PMS / EMR, medical notes, etc. |
| Fieldname | Chiro Condition Manifest Date |
|---|
|
| Description | The date when the chiropractic condition was first manifested or diagnosed. |
| Paper Claim Block | 19 |
| Required / Situational | Situational |
| XML / JSON Field | chiro_manifest_date |
| X12 Loop / Segment | Loop 2310A - REF01, REF02 |
| Allowed Values | Date yyyymmdd |
| Notes | Select "Acute Manifest Date" from the Add Date Field in block 14.
Usually from PMS / EMR, medical notes, etc. |
Professional Claim- Block 21
Diagnosis Codes
| Fieldname | Diagnoses Code A |
|---|
|
| Description | The primary diagnosis code for the patient's condition or ailment. |
| Paper Claim Block | 21 |
| Required / Situational | Required |
| XML / JSON Field | diag_1 |
| X12 Loop / Segment | Loop 2300 -HI01-2 |
| Allowed Values | 8 characters- ICD-10-CM codes (diagnosis codes). |
| Notes | Diag Codes Reference: https://www.cms.gov/medicare/icd-10/2023-icd-10-pcs Usually from PMS / EMR, medical notes, etc. |
Professional Claim- Block 22-23
Resubmission Code / Prior Authorization # / Referral Number / CLIA Number
| Fieldname | Medicaid Resubmission Code |
|---|
|
| Description | Code indicating the reason for resubmitting the claim (e.g., Original Claim, Void/Cancel of Prior Claim, etc.) plus a unique identifier assigned to a specific claim for tracking and internal record-keeping |
| Paper Claim Block | 22 |
| Required / Situational | Situational |
| XML / JSON Field | icn_dcn_1 |
| X12 Loop / Segment | Loop 2300 - CLM05-3, 2300 - REF02 |
| Allowed Values | 32 characters |
| Notes | Resubmission refers to the process of providing the code and original reference number assigned by the destination payer or receiver, indicating a claim or encounter that has been submitted previously. |
| Fieldname | Prior Authorization Number |
|---|
|
| Description | The authorization number obtained from the payer for specific medical services or procedures. |
| Paper Claim Block | 23 |
| Required / Situational | Situational |
| XML / JSON Field | prior_auth |
| X12 Loop / Segment | Loop 2300 - REF02 |
| Allowed Values | 64 Characters |
| Notes | The "Prior Authorization Number" is the payer's assigned authorization number for the service(s). |
| Fieldname | Referral Number |
|---|
|
| Description | The number assigned to a medical referral from one healthcare provider to another. |
| Paper Claim Block | 23 |
| Required / Situational | Situational |
| XML / JSON Field | referral_number |
| X12 Loop / Segment | Loop 2300 - REF02 |
| Allowed Values | 32 characters |
| Notes |
|
Professional Claim- Block 24
Service / Procedure / Charge and Units Information
| Fieldname | Date of Service From |
|---|
|
| Description | The starting date of service for the billed procedure(s). |
| Paper Claim Block | 24A |
| Required / Situational | Required |
| XML / JSON Field | from_date |
| X12 Loop / Segment | Loop 2400 - DTP03 |
| Allowed Values | Date yyyymmdd |
| Notes | Usually from medical records, PMS/EMR, etc. |
| Fieldname | Date of Service To |
|---|
|
| Description | The ending date of service for the billed procedure(s) when multiple days were required. |
| Paper Claim Block | 24A |
| Required / Situational | Situational |
| XML / JSON Field | thru_date |
| X12 Loop / Segment | Loop 2400 - DTP03 |
| Allowed Values | Date yyyymmdd |
| Notes | Usually from medical records, PMS/EMR, etc. |
| Fieldname | Place of Service |
|---|
|
| Description | Code identifying where the services were rendered (e.g., office, home, hospital). |
| Paper Claim Block | Claim Block: 24B |
| Required / Situational | Situational |
| XML / JSON Field | place_of_service |
| X12 Loop / Segment | Loop 2300 CLM05-1 / 2400 - SV105 |
| Allowed Values | 2 characters |
| Notes | Usually from medical records, PMS/EMR, etc. |
| Fieldname | EMG |
|---|
|
| Description | Indicator for emergency services performed. |
| Paper Claim Block | 24C |
| Required / Situational | Situational |
| XML / JSON Field | emergency_indicator |
| X12 Loop / Segment | Loop 2400 - SV109 |
| Allowed Values | Yes/No in dropdown (1 character- "1" for emergency services, "0" for non-emergency services.) |
| Notes | Usually from medical records, PMS/EMR, etc. |
| Fieldname | Procedure Code |
|---|
|
| Description | Code(s) for the specific procedures, services, or supplies provided to the patient. |
| Paper Claim Block | 24D |
| Required / Situational | Required |
| XML / JSON Field | proc_code |
| X12 Loop / Segment | Loop 2400 - SV101 (2-6) |
| Allowed Values | 5 characters - codes identifying the procedures, services, or supplies. |
| Notes | CPT Codes references:Usually from medical records, PMS/EMR, etc. |
| Fieldname | Modifier 1-4 |
|---|
|
| Description | HCPCS 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 Block | 24D |
| Required / Situational | Required |
| XML / JSON Field | mod1, mod2, mod3, mod4 |
| X12 Loop / Segment | Loop 2400 - SV101 (2-6) |
| Allowed Values | 2 characters |
| Notes |
|
| Fieldname | Diagnosis Pointer |
|---|
|
| Description | Pointer(s) to the appropriate diagnosis code(s) in Block 21 related to the service or procedure performed. |
| Paper Claim Block | 24E |
| Required / Situational | Required |
| XML / JSON Field | diag_ref |
| X12 Loop / Segment | Loop 2400 - SV107 (1-4) |
| Allowed Values | 8 characters- Numeric pointers indicating the relevant diagnosis code(s) from Block 21. |
| Notes | Usually from medical records, PMS/EMR, etc. |
| Fieldname | Charge Amount |
|---|
|
| Description | The charges associated with each procedure or service provided. |
| Paper Claim Block | 24F |
| Required / Situational | Required |
| XML / JSON Field | charge |
| X12 Loop / Segment | Loop 2400 - SV102 |
| Allowed Values | 9.2 characters - Monetary amount for each procedure or service. |
| Notes | Usually from medical records, PMS/EMR, etc. |
| Fieldname | Units Qualifier |
|---|
|
| Description | The number of days or units for each procedure or service provided. |
| Paper Claim Block | 24G |
| Required / Situational | Required |
| XML / JSON Field | units |
| X12 Loop / Segment | Loop 2400 - SV104 |
| Allowed Values | 2 characters- Numeric value indicating the number of days or units. |
| Notes | Usually from medical records, PMS/EMR, etc. |
More Information
Must click "Show Additional Charge Fields" to display the following:
- NDC Code
- NDC Dosage
- NDC Measure
- Fields 24H-L
| Fieldname | Additional Narrative |
|---|
|
| Description | A brief text field used to provide supplementary details or context, especially when specific codes are unavailable or not fully descriptive. |
| Paper Claim Block | 24 |
| Required / Situational | Situational |
| XML / JSON Field | narrative |
| X12 Loop / Segment |
|
| Allowed Values | Text 80 |
| Notes | Usually from medical records, PMS/EMR, etc. |
| Fieldname | NDC Code / NDC Dosage / NDC Measure |
|---|
|
| Description | NDC code: A unique identifier assigned to drugs and other healthcare products in the United States for tracking, billing, and drug classification purposes. NDC dosage: The specific strength or concentration of a medication represented by the NDC code, indicating the amount of the active ingredient per unit of administration (e.g., per tablet, per milliliter). NDC measure: The unit of measurement associated with the NDC code, indicating the quantity or volume of the medication or product being dispensed (e.g., number of tablets, milliliters of liquid). |
| Paper Claim Block | Not part of the paper claim HCFA 1500 (hidden under line 24 A-G)
|
| Required / Situational | Situational |
| XML / JSON Field | ndc_code, ndc_dosage, ndc_measure |
| X12 Loop / Segment | N/A |
| Allowed Values | NDC Code (11 characters), NDC Dosage (7 characters), NDC Measure (2 characters) |
| Notes | NDC Code References:
http://www.accessdata.fda.gov/
https://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=ndc |
| Fieldname | EPSDT / Family Plan |
|---|
|
| Description | Indicator for whether the service is related to an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) family plan. |
| Paper Claim Block | 24H |
| Required / Situational | Situational |
| XML / JSON Field | epsdt_indicator |
| X12 Loop / Segment | Loop 2400 - SV111, SV112 |
| Allowed Values | 1 character - "Y" if the service is related to an EPSDT family plan, "N" if not applicable. |
| Notes | Usually from medical records, PMS/EMR, etc. |
| Fieldname | Ordering Provider Last Name, First Name, Middle Name: |
|---|
|
| Description | The personal name details of the healthcare professional responsible for placing an order, typically in the format of last name, first name, and middle name.The personal name details of the healthcare professional responsible for placing an order, typically in the format of last name, first name, and middle name. |
| Paper Claim Block | 24 |
| Required / Situational | Situational |
| XML / JSON Field | ord_prov_name_l, ord_prov_name_f, ord_prov_name_m |
| X12 Loop / Segment | Loop 2420E- NM103, 104, 105 |
| Allowed Values | NDC Code (11 characters), NDC Dosage (7 characters), NDC Measure (2 characters) |
| Notes | NDC Code References:
http://www.accessdata.fda.gov/
https://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=ndc |
| Fieldname | Ordering Provider NPI / Other ID |
|---|
|
| Description | A unique 10-digit identification number assigned to healthcare providers in the United States, used for standardizing and uniquely identifying them in electronic transactions. |
| Paper Claim Block | 24 |
| Required / Situational | Situational |
| XML / JSON Field | ord_prov_npi |
| X12 Loop / Segment | Loop 2420E- NM109, REF01, REF02 |
| Allowed Values | Numeric 10 |
| Notes |
|
| Fieldname | Ordering Provider Address 1 and Address 2: |
|---|
|
| Description | The street address details of the ordering provider, where "Address 1" and "Address 2" may be used for different address lines if needed. |
| Paper Claim Block | 24 |
| Required / Situational | Situational |
| XML / JSON Field | ord_prov_addr_1, ord_prov_addr_2 |
| X12 Loop / Segment | Loop 2420E- N301, N302 |
| Allowed Values | Text 55, 55 |
| Notes |
|
| Fieldname | Ordering Provider City, State, Zip |
|---|
|
| Description | The specific location details of the ordering provider, including the city, state, and ZIP code of their practice or location. |
| Paper Claim Block | 24 |
| Required / Situational | Situational |
| XML / JSON Field | ord_prov_city, ord_prov_state, ord_prov_zip |
| X12 Loop / Segment | Loop 2420E- NM401, 402, 403 |
| Allowed Values | Text 30, 2, 12 |
| Notes |
|
Field not visible on form
| Fieldname | Service Authorization Exception Code |
|---|
|
| Description | Code indicating the reason for the service being exempt from pre-authorization requirements. |
| Paper Claim Block | 24I |
| Required / Situational | Situational |
| XML / JSON Field | chg_prior_auth |
| X12 Loop / Segment | Loop 2310B - PRV02, REF01 / 2420A - PRV02 REF01 |
| Allowed Values | 64 characters |
| Notes | Not on the electronic form |
| Fieldname | Rendering Provider Last Name |
|---|
|
| Description | If a claim level rendering provider is reported on our Claim.MD View/Claim form, it will be displayed in Box 31. Although 24J is normally displayed on paper Claim forms, it is not found on the electronic Claim.MD View/Claim form unless you are reporting a service line level rendering provider for a specific service code. In that case, make sure to click "Show Additional Charge Fields". |
| Paper Claim Block | 24J |
| Required / Situational | Situational |
| XML / JSON Field | ref_name_l |
| X12 Loop / Segment | Loop 2310B - NM1 |
| Allowed Values | 35 characters |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Rendering Provider First Name |
|---|
|
| Description | If a claim level rendering provider is reported on our Claim.MD View/Claim form, it will be displayed in Box 31. Although 24J is normally displayed on paper Claim forms, it is not found on the electronic Claim.MD View/Claim form unless you are reporting a service line level rendering provider for a specific service code. In that case, make sure to click "Show Additional Charge Fields".
|
| Paper Claim Block | 24J |
| Required / Situational | Situational |
| XML / JSON Field | ref_name_f |
| X12 Loop / Segment | Loop 2310B - NM1 |
| Allowed Values | 25 characters |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Rendering Provider Middle Name |
|---|
|
| Description | If a claim level rendering provider is reported on our Claim.MD View/Claim form, it will be displayed in Box 31. Although 24J is normally displayed on paper Claim forms, it is not found on the electronic Claim.MD View/Claim form unless you are reporting a service line level rendering provider for a specific service code. In that case, make sure to click "Show Additional Charge Fields".
|
| Paper Claim Block | 24J |
| Required / Situational | Situational |
| XML / JSON Field | ref_name_m |
| X12 Loop / Segment | Loop 2310B - NM1 |
| Allowed Values | 25 characters |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Rendering Provider Taxonomy # |
|---|
|
| Description | Taxonomy in medical claims uses standardized codes to classify healthcare providers by their type (broad category like physician or clinic), classification (specific field like family medicine), and specialization (focused area like addiction medicine) to ensure accurate billing and claims processing. |
| Paper Claim Block | 24J |
| Required / Situational | Situational |
| XML / JSON Field | prov_taxonomy |
| X12 Loop / Segment | Loop 2310B - PRV03 REF02 / 2420A - PRV03 REF02 |
| Allowed Values | 10 characters |
| Notes | Reference for NPI information: https://taxonomy.nucc.org/ |
| Fieldname | Rendering Provider NPI |
|---|
|
| Description | The National Provider Identifier (NPI) of the healthcare provider who performed the services or procedures. |
| Paper Claim Block | 24J |
| Required / Situational | Situational |
| XML / JSON Field | prov_npi |
| X12 Loop / Segment | Loop 2310B - PRV03 REF02 |
| Allowed Values | 10 characters |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Rendering Provider Atypical ID |
|---|
|
| Description | Atypical identifier for the rendering provider, if applicable. |
| Paper Claim Block | 24J |
| Required / Situational | Situational |
| XML / JSON Field | prov_id |
| X12 Loop / Segment | Loop 2420A - REF |
| Allowed Values | 32 characters |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Facility Name |
|---|
|
| Description | The name of the facility where the services were rendered. |
| Paper Claim Block | 24K |
| Required / Situational | Situational |
| XML / JSON Field | facility_name |
| X12 Loop / Segment | Loop 2310E - NM1 (Service Facility Location Name) |
| Allowed Values | 35 characters |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Facility Address 1 |
|---|
|
| Description | The address line 1 of the facility where the services were rendered. |
| Paper Claim Block | 24K |
| Required / Situational | Situational |
| XML / JSON Field | facility_addr_1 |
| X12 Loop / Segment | Loop 2310E - N3 |
| Allowed Values | 64 characters |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Facility Address 2 |
|---|
|
| Description | The address line 2 of the facility where the services were rendered (if applicable). |
| Paper Claim Block | 24K |
| Required / Situational | Situational |
| XML / JSON Field | facility_addr_2 |
| X12 Loop / Segment | Loop 2310E - N3 |
| Allowed Values | 64 characters |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Facility City |
|---|
|
| Description | The city where the facility is located. |
| Paper Claim Block | 24K |
| Required / Situational | Situational |
| XML / JSON Field | facility_city |
| X12 Loop / Segment | Loop 2310E - N4 |
| Allowed Values | 35 characters |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Facility State |
|---|
|
| Description | The state where the facility is located. |
| Paper Claim Block | 24K |
| Required / Situational | Situational |
| XML / JSON Field | facility_state |
| X12 Loop / Segment | Loop 2310E - N4 |
| Allowed Values | Two-letter state codes |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Facility Zip |
|---|
|
| Description | The ZIP code of the facility where the services were rendered. |
| Paper Claim Block | 24K |
| Required / Situational | Situational |
| XML / JSON Field | facility_zip |
| X12 Loop / Segment | Loop 2310E - N4 |
| Allowed Values | 12 characters |
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Purchased/Referred Service Name |
|---|
|
| Description | The name of the provider or entity to whom the services were purchased or referred. This is used when the services listed on the claim were performed by another provider or entity. |
| Paper Claim Block | 24L |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | Loop 2310F - NM1 |
| Allowed Values |
|
| Notes | Reference for NPI information: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Code (Primary Patient Adjustment Code) |
|---|
|
| Description | The adjustment reason codes communicate to the secondary or tertiary payers what the primary or secondary payers did not pay when they adjudicated the claim. These are the equivalent of sending an electronic EOB. |
| Paper Claim Block | Note: The dropdown on the top must be on SECONDARY, to see the adjustment code fields. This line will display under line 24 A-G. |
| Required / Situational | Situational |
| XML / JSON Field | adj_code_1 adj_cod 2, adj_cod_3, adj_cod_4, adj_code, 5, adj_code_6, adj_code_7, adj_code_8 |
| X12 Loop / Segment | N/A |
| Allowed Values | 6 characters |
| Notes | The adjustment should be used from the previous payers EOB, but the full list can be found here: https://x12.org/codes/claim-adjustment-reason-codes |
| Fieldname | Amount (Primary Patient Adjustment Amount) |
|---|
|
| Description | The adjustment amount is the difference between the total billed charges for medical services and the amount paid by the primary insurance provider, which may be covered by a secondary insurance plan or paid out-of-pocket by the patient. |
| Paper Claim Block | Note: The dropdown on the top must be on SECONDARY, to see the adjustment code fields. This line will display under line 24 A-G. |
| Required / Situational | Situational |
| XML / JSON Field | adj_amt_1, adj_amt_2, adj_amt_3, adj_amt_4, adj_amt_5, adj_amt_6, adj_amt_7, adj_amt_8 |
| X12 Loop / Segment | N/A |
| Allowed Values | Numeric 8.2 |
| Notes |
|
| Fieldname | Remit Date |
|---|
|
| Description | The remit date is the date on which the insurance company or payer issues the payment or explanation of benefits (EOB) for a claim, detailing the adjustments made to the billed charges and the amount the provider will receive. |
| Paper Claim Block | Note: The dropdown on the top must be on SECONDARY, to see the adjustment code fields. This line will display under line 24 A-G. |
| Required / Situational | Situational |
| XML / JSON Field | primary_paid_date |
| X12 Loop / Segment | N/A |
| Allowed Values | date mmddyy |
| Notes |
|
| Fieldname | Paid (Primary Paid Amount) |
|---|
|
| Description | The amount paid by the primary (or if tertiary claim, the secondary) payer. |
| Paper Claim Block | Note: The dropdown on the top must be on SECONDARY (or tertiary), to see the adjustment code fields. This line will display under line 24 A-G. |
| Required / Situational | Situational |
| XML / JSON Field | primary_paid_amount_2 |
| X12 Loop / Segment |
|
| Allowed Values | date mmddyy |
| Notes |
|
Professional Claim- Box 25-30
Tax ID / Patient Acct # / Total Charge / Amount Paid / Balance
| Fieldname | Federal Tax ID Number |
|---|
 
|
| Description | The Federal Tax Identification Number (TIN) of the billing provider or the facility. |
| Paper Claim Block | 25 |
| Required / Situational | Required for group or facility billing, Situational for individual providers |
| XML / JSON Field | bill_taxid |
| X12 Loop / Segment | Loop 2300 - CLM01 |
| Allowed Values | 16 characters |
| Notes | EIN is for "Employment Identification Number" is generally used for identifying a business/organization.
SSN is for Social Security Number and selected for identifying individual providers. |
| Fieldname | Patient's Account Number |
|---|
|
| Description | The patient's account number or identifier used by the billing provider to track the patient's billing and financial information. This is a number decided by the biller or a billing software system. |
| Paper Claim Block | 26 |
| Required / Situational | Required |
| XML / JSON Field | pcn |
| X12 Loop / Segment | Loop 2300 - CLM07 |
| Allowed Values | 1 character "YES" or "NO." |
| Notes | This is either decided by the biller (usually following a convention) or generated from a PMS/EMR system |
| Fieldname | Accept Assignment |
|---|
|
| Description | Indication of whether the billing provider accepts assignment of the claim or not. If "YES," it means the provider accepts the approved charge determined by the payer. If "NO," it means the provider does not accept the approved charge and may bill the patient. |
| Paper Claim Block | 27 |
| Required / Situational | Required |
| XML / JSON Field | accept_assign |
| X12 Loop / Segment | Loop 2300 - CLM07 |
| Allowed Values | 1 character "YES" or "NO." |
| Notes |
|
| Fieldname | Total Charge |
|---|
|
| Description | The total charge for all services rendered to the patient. |
| Paper Claim Block | 28 |
| Required / Situational | Required |
| XML / JSON Field | total_charge |
| X12 Loop / Segment | Loop 2300 - CLM02 |
| Allowed Values | 12.2 |
| Notes |
|
| Fieldname | Amount Paid |
|---|
 |
| Description | The total amount paid by the primary payer. |
| Paper Claim Block | 29 |
| Required / Situational | Situational |
| XML / JSON Field | amount_paid |
| X12 Loop / Segment | Loop 2300 (patient amount paid) , 2320 (payer amount paid) - AMT02 |
| Allowed Values | Numeric 8.2 |
| Notes |
|
| Fieldname | Balance Due |
|---|
|
| Description | The amount remaining to be paid by the patient after considering the total charges, primary payer's payment, and any adjustments or deductions. |
| Paper Claim Block | 30 |
| Required / Situational | Situational |
| XML / JSON Field | balance_due |
| X12 Loop / Segment |
|
| Allowed Values |
|
| Notes |
|
Professional Claim- Block 31
Rendering Provider Information
| Fieldname | Rendering Provider Last Name |
|---|
|
| Description | The last name or surname of the rendering healthcare provider who performed or provided the healthcare services. |
| Paper Claim Block | 31 |
| Required / Situational | Required |
| XML / JSON Field | prov_name_l |
| X12 Loop / Segment | Loop 2310B - NM1 |
| Allowed Values | 35 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Rendering Provider First Name |
|---|
|
| Description | The first name or given name of the rendering healthcare provider who performed or provided the healthcare services. |
| Paper Claim Block | 31 |
| Required / Situational | Required |
| XML / JSON Field | prov_name_f |
| X12 Loop / Segment | Loop 2310B - NM1 (Name) |
| Allowed Values | 25 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Rendering Provider Middle Name |
|---|
|
| Description | The middle name or initial of the rendering healthcare provider who performed or provided the healthcare services. |
| Paper Claim Block | 31 |
| Required / Situational | Situational |
| XML / JSON Field | prov_name_m |
| X12 Loop / Segment | Loop 2310B - NM1 (Name) |
| Allowed Values | 25 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Rendering Provider NPI |
|---|
|
| Description | The National Provider Identifier (NPI) number assigned to the rendering healthcare provider. |
| Paper Claim Block | 31 |
| Required / Situational | Required |
| XML / JSON Field | prov_npi |
| X12 Loop / Segment | Loop 2310B - NM1 |
| Allowed Values | Numeric 10 characters digits representing the unique NPI number assigned to the rendering provider by the National Plan and Provider Enumeration System (NPPES). |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Rendering Provider Atypical ID |
|---|
|
| Description | The unique identification number or code assigned to the rendering healthcare provider by their practice or facility. |
| Paper Claim Block | N/A (Not applicable as this field is not part of the standard CMS-1500 (02/12) paper claim form.) |
| Required / Situational | Situational |
| XML / JSON Field | prov_id |
| X12 Loop / Segment | N/A (Not applicable as this field is not part of the standard X12 EDI format for electronic claim submissions based on the CMS-1500 form.) |
| Allowed Values | 32 characters |
| Notes | The "Provider ID" is not a standard field on the CMS-1500 (02/12) form. If such information is required for a specific claim submission, it may need to be provided as part of supplemental documentation or data accompanying the standard CMS-1500 form. Always check with the insurance payer or electronic claims processing system for any additional data requirements or specific guidelines related to this field. |
Professional Claim- Block 32
Facility Information
| Fieldname | Service Facility Location Name |
|---|
|
| Description | The name of the facility or location where the services were rendered. |
| Paper Claim Block | 32 |
| Required / Situational | Situational |
| XML / JSON Field | facility_name |
| X12 Loop / Segment | Loop 2310C -NM103
N403 |
| Allowed Values | 32 characters |
| Notes |
|
| Fieldname | Service Facility Location Address |
|---|
|
| Description | The address of the facility or location where the services were rendered. |
| Paper Claim Block | 32 |
| Required / Situational | Situational |
| XML / JSON Field | facility_addr_1 |
| X12 Loop / Segment | Loop 2310E - N301 |
| Allowed Values | 64 characters |
| Notes |
|
| Fieldname | Service Facility Location City |
|---|
|
| Description | The city where the facility or location is located. |
| Paper Claim Block | 32 |
| Required / Situational | Situational |
| XML / JSON Field | facility_city |
| X12 Loop / Segment | Loop 2310E - N401 |
| Allowed Values | 32 characters |
| Notes |
|
| Fieldname | Service Facility Location State |
|---|
|
| Description | The state where the facility or location is located. |
| Paper Claim Block | 32 |
| Required / Situational | Situational |
| XML / JSON Field | facility_state |
| X12 Loop / Segment | Loop 2310E - N402 |
| Allowed Values | Two-letter state codes (e.g., CA, NY, TX). |
| Notes |
|
| Fieldname | Service Facility Location ZIP Code |
|---|
|
| Description | The ZIP code of the facility or location where the services were rendered. |
| Paper Claim Block | 32 |
| Required / Situational | Situational |
| XML / JSON Field | facility_zip |
| X12 Loop / Segment | Loop 2310E - N403 (Service Facility Location City, State, ZIP Code) |
| Allowed Values | 12 characters |
| Notes |
|
| Fieldname | Facility NPI |
|---|
|
| Description | The National Provider Identifier (NPI) number assigned to the facility or institution where the healthcare services were rendered or performed. |
| Paper Claim Block | 32a |
| Required / Situational | Situational (If applicable to the claim, the Facility NPI is required.) |
| XML / JSON Field | facility_npi |
| X12 Loop / Segment | Loop 2310C - NM109 |
| Allowed Values | Numeric 10 - Numeric digits representing the unique NPI number assigned to the facility or institution by the National Plan and Provider Enumeration System (NPPES). |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Facility ID |
|---|
|
| Description | The unique identification number assigned to the facility or institution where the healthcare services were rendered or performed. |
| Paper Claim Block | 32b |
| Required / Situational | Situational (If applicable to the claim, the Facility ID is required.) |
| XML / JSON Field | facility_id |
| X12 Loop / Segment | Loop 2310C - REF01, REF02 |
| Allowed Values | 32 characters - Alphanumeric characters, spaces, and special characters representing the facility's unique identification number or code. |
| Notes | The Facility ID is used to uniquely identify the specific facility or institution where the healthcare services were provided. It may be required by certain payers or electronic claims processing systems for claims adjudication and billing purposes. Providers should use the correct Facility ID when submitting claims to ensure accurate processing and reimbursement. |
Professional Claim- Block 33
Billing Provider Information
| Fieldname | Billing Provider Name |
|---|
|
| Description | The name of the billing provider or the entity responsible for submitting the claim. This could be an individual provider's name or the name of a group practice or facility. |
| Paper Claim Block | 33 |
| Required / Situational | Required |
| XML / JSON Field | bill_name |
| X12 Loop / Segment | Loop 2010AA - NM103 |
| Allowed Values | 32 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Billing Provider Address |
|---|
|
| Description | The address of the billing provider or the entity responsible for submitting the claim. Please note: PO Boxes are NOT allowed for primary or secondary billing provider addresses. |
| Paper Claim Block | 33 |
| Required / Situational | Required |
| XML / JSON Field | bill_addr_1 |
| X12 Loop / Segment | Loop 2010AA - N3 01 |
| Allowed Values | 128 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Billing Provider City |
|---|
|
| Description | The city where the billing provider is located. |
| Paper Claim Block | 33 |
| Required / Situational | Required |
| XML / JSON Field | bill_city |
| X12 Loop / Segment | Loop 2010AA - N4 01 (city) |
| Allowed Values | 32 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Billing Provider State |
|---|
|
| Description | The state where the billing provider is located. |
| Paper Claim Block | 33 |
| Required / Situational | Required |
| XML / JSON Field | bill_state |
| X12 Loop / Segment | Loop 2010AA - N4 02 |
| Allowed Values | Two-letter state codes (e.g., CA, NY, TX). |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Billing Provider ZIP Code |
|---|
|
| Description | The ZIP code of the billing provider's location. |
| Paper Claim Block | 33 |
| Required / Situational | Required |
| XML / JSON Field | bill_zip |
| X12 Loop / Segment | Loop 2010AA - N4 03 |
| Allowed Values | 12 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Billing Provider Phone Number |
|---|
Field not in claim form |
| Description | The phone number of the billing provider or the entity submitting the claim. This can include the area code. |
| Paper Claim Block | 33 |
| Required / Situational | Required |
| XML / JSON Field | bill_phone |
| X12 Loop / Segment | Loop 2010AA - PER |
| Allowed Values | 16 characters |
| Notes | Not on the electronic form. Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Billing Provider NPI |
|---|
|
| Description | The National Provider Identifier assigned to a healthcare provider for the purpose of processing and tracking medical claims. |
| Paper Claim Block | 33a |
| Required / Situational | Required |
| XML / JSON Field | bill_npi |
| X12 Loop / Segment | Loop 2010AA / NM1 09 |
| Allowed Values | 10 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Billing Provider Taxonomy |
|---|
|
| Description | The code that specifies the type or classification of healthcare services provided by the billing provider. |
| Paper Claim Block | 33b |
| Required / Situational | Situational |
| XML / JSON Field | bill_taxonomy |
| X12 Loop / Segment | Loop 2000A - PRV03 / 2010AA - REF01, REF02 |
| Allowed Values | 10 characters - representing the specific taxonomy code assigned to the billing provider by relevant healthcare authorities or organizations. |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Fieldname | Billing Provider ID |
|---|
|
| Description | The unique identification number or code assigned to the billing healthcare provider or organization by their practice or facility. |
| Paper Claim Block | 33b |
| Required / Situational | Situational (Required if this is used instead of NPI) |
| XML / JSON Field | bill_id |
| X12 Loop / Segment | Loop 2010BB, REF*G2
|
| Allowed Values | 32 characters |
| Notes | The "Billing Provider ID" is not a standard field on the CMS-1500 (02/12) form. If such information is required for a specific claim submission, it may need to be provided as part of supplemental documentation or data accompanying the standard CMS-1500 form. Always check with the insurance payer or electronic claims processing system for any additional data requirements or specific guidelines related to this field. |
| Fieldname | Pay-To Provider Name |
|---|
|
| Description | The information in this box must match the pay-to information that is being electronically billed.
|
| Paper Claim Block | 33 |
| Required / Situational | Situational |
| XML / JSON Field | pay_name
|
| X12 Loop / Segment | Loop 2010AB, NM1/87
|
| Allowed Values | Text 50
|
| Notes |
|
| Fieldname | Pay-To Provider Address |
|---|
|
| Description | The information in this box must match the pay-to information that is being electronically billed.
|
| Paper Claim Block | 33 |
| Required / Situational | Situational |
| XML / JSON Field | pay_addr_1, pay addr_2
|
| X12 Loop / Segment | Loop 2010AB, N3, 01, 02, 87
|
| Allowed Values | Text 55
|
| Notes |
|
| Fieldname | Pay-To Provider City |
|---|
|
| Description | The information in this box must match the pay-to information that is being electronically billed.
|
| Paper Claim Block | 33 |
| Required / Situational | Situational |
| XML / JSON Field | pay_city
|
| X12 Loop / Segment | Loop 2010AB, N4, 01, 87
|
| Allowed Values | Text 30
|
| Notes |
|
| Fieldname | Pay-To Provider State |
|---|
|
| Description | The information in this box must match the pay-to information that is being electronically billed.
|
| Paper Claim Block | 33 |
| Required / Situational | Situational |
| XML / JSON Field | pay_state
|
| X12 Loop / Segment | Loop 2010AB, N4, 02, 87
|
| Allowed Values | Text 2
|
| Notes |
|
| Fieldname | Pay-To Provider Zip |
|---|
|
| Description | The information in this box must match the pay-to information that is being electronically billed.
|
| Paper Claim Block | 33 |
| Required / Situational | Situational |
| XML / JSON Field | pay_zip
|
| X12 Loop / Segment | Loop 2010AB, N4, 03, 87
|
| Allowed Values | Text 12
|
| Notes |
|
