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    Professional Claim Form Overview
    • 04 Mar 2025
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    Professional Claim Form Overview

    • Actualizado en 04 Mar 2025
    • 40 Minutos para leer
    • Impresión
    • Oscuro
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    • PDF
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    Resumen del artículo

    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

    DescriptionThe name of the insurance payer or health plan.
    Paper Claim Block1
    Required / SituationalRequired
    XML / JSON Fieldpayer_name
    X12 Loop / SegmentLoop 2010BB / NM103
    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

    Payer ID

    DescriptionThe unique identifier for the primary payer. 
    Paper Claim Block1
    Required / SituationalRequired
    XML / JSON Fieldpayerid
    X12 Loop / SegmentLoop 2000B / SBR09
    Allowed Values32 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

    Payer Address

    DescriptionThe address of the insurance payer or health plan.
    Paper Claim Block1
    Required / SituationalSituational
    XML / JSON Fieldpayer_addr_1
    X12 Loop / SegmentLoop 2010BB / N301
    Allowed Values55 characters
    NotesInformation obtained from insurance card or directly from insurance provider.
    Payer address is not required on electronic claims.
    Field Name

    Payer Address 2

    DescriptionAdditional address line of the insurance payer or health plan.
    Paper Claim Block1
    Required / SituationalSituational
    XML / JSON Fieldpayer_addr_2
    X12 Loop / SegmentLoop 2010BB / N302
    Allowed Values55 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. Create a support ticket if a payer is not on the list.  
    Field Name

    Payer City

    DescriptionThe name of the insurance payer or health plan.
    Paper Claim Block1
    Required / SituationalSituational
    XML / JSON Fieldpayer_city
    X12 Loop / SegmentLoop 2010BB / N401
    Allowed Values30 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. Create a support ticket if a payer is not on the list.  
    Field Name

    Payer State

    DescriptionThe state where the insurance payer or health plan is located.
    Paper Claim Block1
    Required / SituationalSituational
    XML / JSON Fieldpayer_state
    X12 Loop / SegmentLoop 2010BB / N402
    Allowed Values2 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. Create a support ticket if a payer is not on the list.  
    Field Name

    Payer Zip Code

    DescriptionThe ZIP code of the insurance payer or health plan.
    Paper Claim Block1
    Required / SituationalSituational
    XML / JSON Fieldpayer_zip
    X12 Loop / SegmentLoop 2010BB / N403
    Allowed Values15 characters
    Notes


    Field Name

    Insured I.D. Number

    DescriptionThe identification number of the insured individual.
    Paper Claim Block1a
    Required / SituationalRequired
    XML / JSON Fieldins_number
    X12 Loop / SegmentLoop 2010BA  / NM109
    Allowed Values32 characters
    NotesProvide 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

    DescriptionThe full last name, first name, and middle initial of the patient receiving the medical services.
    Paper Claim Block2
    Required / SituationalRequired (except for middle initial)
    XML / JSON Field:

    pat_name_l, pat_name_f, pat_name_m

    X12 Loop / SegmentLoop 2010BA / NM103 / NM104 / NM105
    Allowed Values35 characters (last name) / 25 characters (first name) / 25 characters (middle initial)
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
    Field Name

    Patient Date of Birth

    FieldnamePatient Date of Birth
    DescriptionThe date of birth of the patient.
    Paper Claim Block3
    Required / SituationalRequired
    XML / JSON Fieldpat_dob
    X12 Loop / SegmentLoop 2010BA / DMG02
    Allowed Values10 characters, Date format (MM-DD-YYYY)
    NoteInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
    Field Name

    Patient Sex

    Description

     The sex of the patient.

    Paper Claim Block2
    Required / SituationalRequired
    XML / JSON Fieldpatient_sex
    X12 Loop / SegmentLoop 2010BA / DMG03
    Allowed Values

    1 character - M (Male), F (Female), U (Unknown)

    NoteInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

    Field Name

    Insured's Name

    DescriptionThe full last name, full first name, middle initial of insured individual. The insured individual is the person who holds the policy. 
    Paper Claim Block4
    Required / SituationalSituational
    XML / JSON Fieldins_name_l, ins_name_f, ins_name_m
    X12 Loop / SegmentLoop 2010BA / NM103, NM104, NM105, NM107
    Allowed Values

    35 characters (last name) / 25 characters (first name) / 25 characters (middle initial)

    NoteInformation usually obtained from insurance card.
    Professional Claim- Block 5-8
    Patient Information / Insured's Information
    Field Name

    Patient Address

    DescriptionThe first line of the patient's address.
    Paper Claim Block5
    Required / SituationalRequired
    XML / JSON Fieldins_addr_1
    X12 Loop / SegmentLoop 2010CA / N301
    Allowed Values55 characters
    NoteInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
    Field Name

    Patient Address 2

    DescriptionThe second line of the patient's address (if applicable).
    Paper Claim Block5
    Required / SituationalSituational
    XML / JSON Fieldins_addr_2
    X12 Loop / SegmentLoop 2010CA / N302
    Allowed Values55 characters
    NoteInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
    Field Name

    Patient City

    DescriptionThe city where the patient resides.
    Paper Claim Block5
    Required / SituationalRequired
    XML / JSON Fieldpat_city
    X12 Loop / SegmentLoop 2010CA / N401
    Allowed Values30 characters
    NoteInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
    Field Name

    Patient State

    DescriptionThe state where the patient resides.
    Paper Claim Block5
    Required / SituationalRequired
    XML / JSON Fieldpat_state
    X12 Loop / SegmentLoop 2010CA / N402
    Allowed Values2 characters
    NoteInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
    Field Name

    Patient Zip Code

    DescriptionThe ZIP code of the patient's address.
    Paper Claim Block5
    Required / SituationalRequired
    XML / JSON Fieldpat_zip
    X12 Loop / Segment Loop 2010CA / N403
    Allowed Values15 characters
    NoteInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
    Field Name

    Patient Country Code


    DescriptionThe country code of the patient's address (if applicable).
    Paper Claim Block5
    Required / SituationalSituational
    XML / JSON Fieldpat_country
    X12 Loop / SegmentLoop 2010CA - N4
    Allowed Values2 characters
    NoteInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
    Field Name

    Patient Phone Number


    DescriptionThe phone number of the patient.
    Paper Claim Block5

    Required / Situational: Situational

    		Situational
    XML / JSON Field:pat_phone
    X12 Loop / SegmentLoop 2010CA - PER
    Allowed Values10 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)
    NoteInformation 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 / Segment2010BA - N301
    Allowed Values
    		55 characters
    NoteInformation 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 Fieldins_addr_2
    X12 Loop / Segment
    		Loop 2010BA - N302
    Allowed Values
    		55 characters
    NoteInformation 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 
    NoteInformation 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 / SituationalSituational
    XML / JSON Field
    		ins_zip
    X12 Loop / Segment
    		2010BA - N403
    Allowed Values
    		15 characters
    NoteInformation 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 / SituationalSituational
    XML / JSON Field
    		ins_country
    X12 Loop / Segment
    		Loop 2010BA - N4
    Allowed Values
    		2 characters
    NoteInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

    Field not visible on claim form

    Field Name

    Insured Phone Number

    DescriptionThe phone number of the insured individual.
    Paper Claim Block7
    Required / SituationalSituational
    XML / JSON Fieldins_phone
    X12 Loop / SegmentLoop 2010BA - PER
    Allowed Values10 characters
    NoteNot 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)
    NoteInformation 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

    DescriptionThe last name or surname of the insured individual for other insurance.
    Paper Claim Block9
    Required / SituationalSituational
    XML / JSON Fieldother_ins_name_l
    X12 Loop / SegmentLoop 2330A- NM103 (Name)
    Allowed Values35 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Insured First Name

    DescriptionThe last name or surname of the insured individual for other insurance.
    Paper Claim Block9
    Required / SituationalSituational
    XML / JSON Fieldother_ins_name_f
    X12 Loop / SegmentLoop 2330A- NM104 (Name)
    Allowed Values35 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Insured's Middle Name

    DescriptionThe middle name or initial of the insured individual for other insurance.
    Paper Claim Block9
    Required / SituationalSituational
    XML / JSON Field:other_ins_name_m
    X12 Loop / SegmentLoop 2330A - NM105
    Allowed Values25 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Insured's Policy Number

    DescriptionThe policy number associated with the other insurance coverage.
    Paper Claim Block9a
    Required / SituationalSituational
    XML / JSON Fieldother_ins_number
    X12 Loop / SegmentLoop 2320 - SBR03
    Allowed Values32 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Insured's Date of Birth

    DescriptionThe date of birth of the insured individual for other insurance.
    Paper Claim Block9b (this field is typically not part of the standard CMS-1500 (02/12) paper claim form.)
    Required / SituationalSituational
    XML / JSON Fieldother_ins_dob
    X12 Loop / SegmentLoop 2320B- DMG02
    Allowed ValuesDate format (yyyymmdd)
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Insured's Sex

    DescriptionThe gender or sex of the insured individual for other insurance.
    Paper Claim Block9b (this field is typically not part of the standard CMS-1500 (02/12) paper claim form.)
    Required / SituationalSituational
    XML / JSON Fieldother_ins_sex
    X12 Loop / SegmentLoop 2320B - DMG03
    Allowed Values2 characters - M (Male), F (Female), U (Unknown), or other valid gender codes.
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Payment Date

    DescriptionThe "Primary Payment Date" refers to the date when the primary insurance payer made the payment for the healthcare services rendered.
    Paper Claim Block9c (this field is not part of the standard CMS-1500 (02/12) paper claim form.)
    Required / SituationalN/A (Not applicable as this field is not included in the standard CMS-1500 (02/12) paper claim form.)
    XML / JSON Fieldother_ins_payment_date
    X12 Loop / Segment

    Loop 2330B / Segment DTP / Qualifier 573

    Allowed ValuesDate yyyymmdd
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Payer's Name

    DescriptionThe name of the other insurance payer or health plan that is responsible for processing the claim as a secondary or tertiary payer.
    Paper Claim Block9d
    Required / SituationalSituational
    XML / JSON Fieldother_payer_name
    X12 Loop / SegmentLoop 2320 - SBR04 OI
    Allowed Values32 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Insurance Payer ID

    DescriptionThe identification number of the insurance payer for other insurance.
    Paper Claim Block9d
    Required / SituationalSituational
    XML / JSON Fieldother_payerid
    X12 Loop / SegmentLoop 2320 - REF01
    Allowed Values8 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
    Fieldname

    Secondary Payer Filing Code (Medicare Type Code)

    DescriptionA 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 Block9d
    Required / SituationalSituational
    XML / JSON Fieldother_claimfilingcode
    X12 Loop / SegmentLoop 2320 - SBR09
    Allowed ValuesText 2. Example (12- Working Age, 43- Medicare Disabled, etc.). 
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.
    Fieldname

    Secondary Payer's Claim ID

    DescriptionThe unique identification number assigned to the claim by the other insurance payer.
    Paper Claim Block9d
    Required / SituationalSituational
    XML / JSON Fieldother_payerid
    X12 Loop / SegmentLoop 2320 - REF02
    Allowed ValuesAllowed Values
    NotesInformation 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 Block9d
    Required / SituationalSituational
    XML / JSON Fieldother_payer_addr_1
    X12 Loop / SegmentLoop 2320 / N301
    Allowed Values 55 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.



    Fieldname

    Secondary Payer Address 2

    DescriptionThe second line of the address of the other insurance payer.
    Paper Claim Block9d
    Required / SituationalSituational
    XML / JSON Fieldother_payer_addr_2
    X12 Loop / SegmentLoop 2320 / N302
    Allowed Values55 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Payer City

    DescriptionThe city where the other insurance payer is located.
    Paper Claim Block9d
    Required / SituationalSituational
    XML / JSON Fieldother_payer_city
    X12 Loop / SegmentLoop 2320 / N401
    Allowed Values2 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Payer State

    DescriptionThe state where the other insurance payer is located.
    Paper Claim Block9d
    Required / SituationalSituational
    XML / JSON Fieldother_payer_state
    X12 Loop / SegmentLoop 2320 / N402
    Allowed ValuesTwo-letter state abbreviation.
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

    Fieldname

    Secondary Payer Zip

    DescriptionThe ZIP code of the other insurance payer's location.
    Paper Claim Block9d
    Required / SituationalSituational
    XML / JSON Fieldother_payer_zip
    X12 Loop / SegmentLoop 2320 / N403
    Allowed Values15 characters
    Notes Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Medicare Type Code

    DescriptionThe Medicare Type Code indicates the type of Medicare program or plan under which the patient is covered.
    Paper Claim Block9d
    Required / SituationalSituational
    XML / JSON Fieldother_ins_medicare_code
    X12 Loop / SegmentLoop 2300 / EB04
    Allowed Values2 characters
    NoteThe 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

    DescriptionThe relationship of the insured to the policyholder or primary beneficiary of the other insurance policy.
    Paper Claim Block9e
    Required / SituationalSituational
    XML / JSON Fieldother_pat_rel
    X12 Loop / SegmentLoop 2320B / SBR02
    Allowed Values2 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Policy Group Name

    DescriptionThe name of the group or employer providing the other insurance coverage, if applicable.
    Paper Claim Block9f
    Required / SituationalSituational
    XML / JSON Field other_ins_group
    X12 Loop / SegmentLoop 2320B - REF02
    Allowed Values30 characters
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Secondary Policy Number

    DescriptionThe identification number or code of the other insurance policy covering the patient's healthcare services.
    Paper Claim Block9g
    Required / SituationalSituational
    XML / JSON Field other_ins_number
    X12 Loop / SegmentLoop 2320B - REF01
    Allowed Values30 characters
    NotesInformation 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 Block10a
    Required / SituationalSituational
    XML / JSON Fieldemployment_related
    X12 Loop / Segment Loop 2300 - CLM11 PWK
    Allowed Values1 character - Y (Yes), N (No)
    Notes


    Fieldname

    Accident Related to Auto

    DescriptionIndicates whether the accident is related to an automobile accident.
    Paper Claim Block10b
    Required / SituationalSituational
    XML / JSON Fieldauto_accident
    X12 Loop / SegmentLoop 2300 - CLM11 PWK
    Allowed Values1 character - Y (Yes), N (No)
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Auto Accident State

    DescriptionThe state where the auto accident occurred.
    Paper Claim Block10b
    Required / SituationalSituational
    XML / JSON Fieldauto_accident_state
    X12 Loop / SegmentLoop 2300 - CLM11 PWK (Claim Supplemental Information)
    Allowed ValuesTwo-letter state abbreviation
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Other Accident Related

    DescriptionIndicates whether the accident is related to another type of accident.
    Paper Claim Block10c
    Required / SituationalSituational
    XML / JSON Fieldother_accident
    X12 Loop / Segment Loop 2300 - CLM11 PWK
    Allowed Values 1 character - Y (Yes), N (No)
    NotesInformation obtained from intake forms and/or PMS / EMR systems, insurance information, etc.


    Fieldname

    Condition Code (1, 2, 3)

    DescriptionClaim 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 Block10d
    Required / SituationalSituational
    XML / JSON Fieldcond_code_1, cond_code_2, cond_code_3
    X12 Loop / SegmentLoop 2300 - HI CLM
    Allowed Values2 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

    NotesThe 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

    DescriptionThe group number associated with the insured individual's insurance plan.
    Paper Claim Block11
    Required / SituationalSituational
    XML / JSON Fieldins_group
    X12 Loop / SegmentLoop 2000B - SBR03 REF
    Allowed Values30 characters
    NotesInsurance Information



    Fieldname

    Insured Date of Birth

    DescriptionThe date of birth of the insured individual.
    Paper Claim Block11a
    Required / SituationalSituational
    XML / JSON Fieldins_dob
    X12 Loop / SegmentLoop 2010BA - DMG02
    Allowed ValuesDate format yyyymmdd
    NotesInsurance Information


    Fieldname

    Insured Gender

    DescriptionThe gender of the insured individual.
    Paper Claim Block11a
    Required / SituationalSituational
    XML / JSON Fieldins_sex
    X12 Loop / SegmentLoop 2010BA - DMG03
    Allowed Values1 character - M (Male), F (Female), U (Unknown)
    NotesInsurance Information


    Fieldname

    Insured Employer Name/School Name/ Other Claim ID

    DescriptionThe name of the insured individual's employer.
    Paper Claim Block11b
    Required / SituationalSituational
    XML / JSON Fieldins_employer
    X12 Loop / SegmentLoop 2010BA - REF01, REF02
    Allowed Values32 characters
    NotesInsurance Information


    Fieldname

    Insured Plan Name

    DescriptionThe name of the insured individual's insurance plan.
    Paper Claim Block11c
    Required / SituationalSituational
    XML / JSON Fieldins_plan
    X12 Loop / SegmentLoop 2000B - SBR04
    Allowed Values30 characters
    NotesInsurance Information


    Fieldname

    Supervising Provider Name / ID / NPI

    DescriptionThe name of the supervisor or overseeing healthcare professional who provided or supervised the healthcare services.
    Paper Claim Block2310D
    Required / SituationalSituational
    XML / JSON Fieldchg_supv_prov_name_l, chg_supv_prov_name_f, chg_supv_prov_name_m, chg_supv_prov_npi, chg_supv_prov_id
    X12 Loop / SegmentN/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 Values55 characters
    NotesInsurance 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)

    DescriptionThe date when the current illness, injury, or pregnancy began.
    Paper Claim Block14
    Required / SituationalSituational
    XML / JSON Fieldcond_date
    X12 Loop / SegmentLoop 2300 - DTP01 / DTP03
    Allowed Values Date yyyymmdd
    NotesUsually from PMS / EMR, medical notes, etc.


    Fieldname

    Date of Onset

    DescriptionThe date when the patient's symptoms or condition first started or when an injury occurred.
    Paper Claim Block15
    Required / SituationalSituational
    XML / JSON Fieldonset_date
    X12 Loop / SegmentLoop 2300 - DTP01, DTP03
    Allowed ValuesDate yyyymmdd
    NotesUsually from PMS / EMR, medical notes, etc.


    Fieldname

    Date Last Seen

    DescriptionThe date when the patient was last seen for treatment or evaluation.
    Paper Claim Block:15
    Required / SituationalSituational
    XML / JSON Fieldlastseen_date
    X12 Loop / Segment Loop 2300 - DTP01, DT03
    Allowed ValuesDate format yyyymmdd
    NotesThis 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

    DescriptionThe date when the patient became unable to work due to the reported condition or injury.
    Paper Claim Block16
    Required / SituationalSituational
    XML / JSON Fieldnowork_from_date
    X12 Loop / Segment Loop 2300 - DTP03
    Allowed ValuesDate yyyymmdd
    NotesUsually from PMS / EMR, medical notes, etc.


    Fieldname

    Unable to Work To Date

    DescriptionThe 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 Block16
    Required / SituationalSituational
    XML / JSON Field nowork_from_date
    X12 Loop / SegmentLoop 2300 - DTP03
    Allowed ValuesDate yyyymmdd
    NotesUsually from PMS / EMR, medical notes, etc.


    Fieldname

    Referring Provider Last Name

    Description

    The last name or surname of the referring provider.

    Paper Claim Block17
    Required / Situational:Situational
    XML / JSON Field ref_name_l
    X12 Loop / SegmentLoop 2310A - NM101
    Allowed Values35 characters
    NotesUsually from PMS / EMR, medical notes, etc.
    Reference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Referring Provider First Name

    DescriptionThe first name or given name of the referring provider.
    Paper Claim Block17
    Required / SituationalSituational
    XML / JSON Fieldref_name_f
    X12 Loop / Segment Loop 2310A - NM103
    Allowed Values25 characters
    NotesUsually from PMS / EMR, medical notes, etc.
    Reference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Referring Provider Middle Name

    DescriptionThe middle name or initial of the referring provider.
    Paper Claim Block17
    Required / SituationalSituational
    XML / JSON Field:ref_name_m
    X12 Loop / SegmentLoop 2310A - NM104
    Allowed Values25 characters
    NotesUsually from PMS / EMR, medical notes, etc.
    Reference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Referring Provider NPI

    DescriptionThe National Provider Identifier (NPI) of the referring provider.
    Paper Claim BlockBlock: 17a
    Required / SituationalSituational
    XML / JSON Fieldref_npi
    X12 Loop / SegmentLoop 2310A - NM109
    Allowed ValuesNumeric 10 characters
    NotesUsually from PMS / EMR, medical notes, etc.
    Reference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Referring Provider Atypical ID

    DescriptionThe atypical ID associated with the referring provider, if applicable.
    Paper Claim Block17b
    Required / SituationalSituational
    XML / JSON Fieldref_id
    X12 Loop / Segment Loop 2310A - REF01, REF02
    Allowed Values:32 characters
    NotesUsually 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

    DescriptionThe date when the patient was admitted to the hospital.
    Paper Claim Block18
    Required / Situational Situational
    XML / JSON Field:hosp_from_date
    X12 Loop / Segment: Loop 2300 - DTP03
    Allowed ValuesDate yyyymmdd
    NotesUsually from PMS / EMR, medical notes, etc.


    Fieldname

    Hospital Discharge Date

    DescriptionThe date when the patient was discharged from the hospital.
    Paper Claim Block18
    Required / SituationalSituational
    XML / JSON Fieldhosp_thru_date
    X12 Loop / SegmentLoop 2300 - DTP03
    Allowed ValuesDate yyyymmdd
    NotesUsually from PMS / EMR, medical notes, etc. 


    Fieldname

    Chiro Condition Manifest Date

    DescriptionThe date when the chiropractic condition was first manifested or diagnosed.
    Paper Claim Block19
    Required / SituationalSituational
    XML / JSON Field chiro_manifest_date
    X12 Loop / SegmentLoop 2310A - REF01, REF02
    Allowed ValuesDate yyyymmdd
    NotesSelect "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

    DescriptionThe primary diagnosis code for the patient's condition or ailment.
    Paper Claim Block21
    Required / SituationalRequired
    XML / JSON Fielddiag_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

    DescriptionCode 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 Block22
    Required / SituationalSituational
    XML / JSON Fieldicn_dcn_1
    X12 Loop / SegmentLoop 2300 - CLM05-3, 2300 - REF02
    Allowed Values32 characters
    NotesResubmission 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

    DescriptionThe authorization number obtained from the payer for specific medical services or procedures.
    Paper Claim Block23
    Required / SituationalSituational
    XML / JSON Fieldprior_auth
    X12 Loop / SegmentLoop 2300 - REF02
    Allowed Values64 Characters
    NotesThe "Prior Authorization Number" is the payer's assigned authorization number for the service(s).


    Fieldname

    Referral Number

    DescriptionThe number assigned to a medical referral from one healthcare provider to another.
    Paper Claim Block23
    Required / SituationalSituational
    XML / JSON Fieldreferral_number
    X12 Loop / SegmentLoop 2300 - REF02
    Allowed Values32 characters
    Notes


    Fieldname

    CLIA Number

    DescriptionClinical Laboratory Improvement Amendments (CLIA) number assigned to the laboratory performing the tests.
    Paper Claim Block23
    Required / SituationalSituational
    XML / JSON Fieldclia_number
    X12 Loop / Segment Loop 2300 - REF02
    Allowed Values32 characters
    Notes

    CLIA Number reference:

    https://qcor.cms.gov/advanced_find_provider.jsp?which=4&backReport=active_CLIA.jsp


    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 Block24A
    Required / SituationalRequired
    XML / JSON Fieldfrom_date
    X12 Loop / SegmentLoop 2400 - DTP03
    Allowed Values Date yyyymmdd
    NotesUsually from medical records, PMS/EMR, etc.


    Fieldname

    Date of Service To

    DescriptionThe ending date of service for the billed procedure(s) when multiple days were required.
    Paper Claim Block24A
    Required / SituationalSituational
    XML / JSON Fieldthru_date
    X12 Loop / SegmentLoop 2400 - DTP03
    Allowed ValuesDate yyyymmdd
    NotesUsually from medical records, PMS/EMR, etc.


    Fieldname

    Place of Service

    DescriptionCode identifying where the services were rendered (e.g., office, home, hospital).
    Paper Claim BlockClaim Block: 24B
    Required / SituationalSituational
    XML / JSON Fieldplace_of_service
    X12 Loop / SegmentLoop 2300 CLM05-1 / 2400 - SV105
    Allowed Values 2 characters
    NotesUsually from medical records, PMS/EMR, etc.


    Fieldname

    EMG

    DescriptionIndicator for emergency services performed.
    Paper Claim Block24C
    Required / SituationalSituational
    XML / JSON Field emergency_indicator
    X12 Loop / SegmentLoop 2400 - SV109
    Allowed ValuesYes/No in dropdown (1  character- "1" for emergency services, "0" for non-emergency services.) 
    NotesUsually from medical records, PMS/EMR, etc.


    Fieldname

    Procedure Code

    DescriptionCode(s) for the specific procedures, services, or supplies provided to the patient.
    Paper Claim Block24D
    Required / SituationalRequired
    XML / JSON Fieldproc_code
    X12 Loop / SegmentLoop 2400 - SV101 (2-6)
    Allowed Values5 characters - codes identifying the procedures, services, or supplies.
    NotesCPT Codes references:Usually from medical records, PMS/EMR, etc.

    Fieldname

    Modifier 1-4

    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 Block24D
    Required / SituationalRequired
    XML / JSON Fieldmod1, mod2, mod3, mod4
    X12 Loop / SegmentLoop 2400 - SV101 (2-6)
    Allowed Values2 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 Block24E
    Required / SituationalRequired
    XML / JSON Fielddiag_ref
    X12 Loop / SegmentLoop 2400 - SV107 (1-4)
    Allowed Values8 characters- Numeric pointers indicating the relevant diagnosis code(s) from Block 21.
    NotesUsually from medical records, PMS/EMR, etc.


    Fieldname

    Charge Amount

    DescriptionThe charges associated with each procedure or service provided.
    Paper Claim Block24F
    Required / SituationalRequired
    XML / JSON Fieldcharge
    X12 Loop / SegmentLoop 2400 - SV102
    Allowed Values9.2 characters - Monetary amount for each procedure or service.
    NotesUsually from medical records, PMS/EMR, etc.


    Fieldname

    Units Qualifier

    DescriptionThe number of days or units for each procedure or service provided.
    Paper Claim Block24G
    Required / SituationalRequired
    XML / JSON Fieldunits
    X12 Loop / SegmentLoop 2400 - SV104
    Allowed Values2 characters- Numeric value indicating the number of days or units.
    NotesUsually 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

    DescriptionA brief text field used to provide supplementary details or context, especially when specific codes are unavailable or not fully descriptive.
    Paper Claim Block24
    Required / SituationalSituational
    XML / JSON Fieldnarrative
    X12 Loop / Segment
    Allowed ValuesText 80
    NotesUsually 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 BlockNot part of the paper claim HCFA 1500 (hidden under line 24 A-G)
    Required / SituationalSituational
    XML / JSON Fieldndc_code, ndc_dosage, ndc_measure
    X12 Loop / SegmentN/A
    Allowed ValuesNDC 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

    DescriptionIndicator for whether the service is related to an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) family plan.
    Paper Claim Block24H
    Required / SituationalSituational
    XML / JSON Fieldepsdt_indicator
    X12 Loop / SegmentLoop 2400 - SV111, SV112
    Allowed Values1 character - "Y" if the service is related to an EPSDT family plan, "N" if not applicable.
    NotesUsually 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 Block24
    Required / SituationalSituational
    XML / JSON Field

    ord_prov_name_l, ord_prov_name_f, ord_prov_name_m

    X12 Loop / SegmentLoop 2420E- NM103, 104, 105
    Allowed ValuesNDC 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 Block24
    Required / SituationalSituational
    XML / JSON Field

    ord_prov_npi

    X12 Loop / SegmentLoop 2420E- NM109, REF01, REF02
    Allowed ValuesNumeric 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 Block24
    Required / SituationalSituational
    XML / JSON Field

    ord_prov_addr_1, ord_prov_addr_2

    X12 Loop / SegmentLoop 2420E- N301, N302
    Allowed ValuesText 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 Block24
    Required / SituationalSituational
    XML / JSON Field

    ord_prov_city, ord_prov_state, ord_prov_zip

    X12 Loop / SegmentLoop 2420E- NM401, 402, 403
    Allowed ValuesText 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 Block24I
    Required / SituationalSituational
    XML / JSON Fieldchg_prior_auth
    X12 Loop / SegmentLoop 2310B - PRV02, REF01 / 2420A - PRV02 REF01
    Allowed Values64 characters
    NotesNot on the electronic form
    Fieldname

    Rendering Provider Last Name

    DescriptionIf 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 Block24J
    Required / SituationalSituational
    XML / JSON Fieldref_name_l
    X12 Loop / SegmentLoop 2310B - NM1 
    Allowed Values35 characters
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Rendering Provider First Name

    DescriptionIf 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 Block24J
    Required / SituationalSituational
    XML / JSON Fieldref_name_f
    X12 Loop / SegmentLoop 2310B - NM1
    Allowed Values25 characters
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Rendering Provider Middle Name

    DescriptionIf 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 Block24J
    Required / SituationalSituational
    XML / JSON Fieldref_name_m
    X12 Loop / SegmentLoop 2310B - NM1
    Allowed Values25 characters
    NotesReference 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 Block24J
    Required / SituationalSituational
    XML / JSON Fieldprov_taxonomy
    X12 Loop / SegmentLoop 2310B - PRV03 REF02 / 2420A - PRV03 REF02
    Allowed Values10 characters
    NotesReference for NPI information: https://taxonomy.nucc.org/


    Fieldname

    Rendering Provider NPI

    DescriptionThe National Provider Identifier (NPI) of the healthcare provider who performed the services or procedures.
    Paper Claim Block24J
    Required / SituationalSituational
    XML / JSON Fieldprov_npi
    X12 Loop / SegmentLoop 2310B - PRV03 REF02
    Allowed Values10 characters
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Rendering Provider Atypical ID

    DescriptionAtypical identifier for the rendering provider, if applicable.
    Paper Claim Block24J
    Required / SituationalSituational
    XML / JSON Fieldprov_id
    X12 Loop / SegmentLoop 2420A - REF
    Allowed Values32 characters
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Facility Name

    DescriptionThe name of the facility where the services were rendered.
    Paper Claim Block24K
    Required / SituationalSituational
    XML / JSON Fieldfacility_name
    X12 Loop / SegmentLoop 2310E - NM1 (Service Facility Location Name)
    Allowed Values35 characters
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Facility Address 1

    DescriptionThe address line 1 of the facility where the services were rendered.
    Paper Claim Block24K
    Required / SituationalSituational
    XML / JSON Fieldfacility_addr_1
    X12 Loop / SegmentLoop 2310E - N3
    Allowed Values64 characters
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Facility Address 2

    DescriptionThe address line 2 of the facility where the services were rendered (if applicable).
    Paper Claim Block24K
    Required / SituationalSituational
    XML / JSON Fieldfacility_addr_2
    X12 Loop / SegmentLoop 2310E - N3
    Allowed Values64 characters
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Facility City

    DescriptionThe city where the facility is located.
    Paper Claim Block24K
    Required / SituationalSituational
    XML / JSON Fieldfacility_city
    X12 Loop / SegmentLoop 2310E - N4 
    Allowed Values35 characters
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Facility State

    Description The state where the facility is located.
    Paper Claim Block24K
    Required / SituationalSituational
    XML / JSON Fieldfacility_state
    X12 Loop / SegmentLoop 2310E - N4 
    Allowed ValuesTwo-letter state codes
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Facility Zip

    DescriptionThe ZIP code of the facility where the services were rendered.
    Paper Claim Block24K
    Required / SituationalSituational
    XML / JSON Fieldfacility_zip
    X12 Loop / SegmentLoop 2310E - N4
    Allowed Values12 characters
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Purchased/Referred Service Name

    DescriptionThe 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 Block24L
    Required / SituationalSituational
    XML / JSON FieldN/A
    X12 Loop / Segment Loop 2310F - NM1 
    Allowed Values
    NotesReference for NPI information: https://npiregistry.cms.hhs.gov/search
    Fieldname

    Code (Primary Patient Adjustment Code)

    DescriptionThe 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 BlockNote: 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 / SituationalSituational
    XML / JSON Fieldadj_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 / SegmentN/A
    Allowed Values6 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)

    DescriptionThe 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 BlockNote: 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 / SituationalSituational
    XML / JSON Fieldadj_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 / SegmentN/A
    Allowed ValuesNumeric 8.2
    Notes



    Fieldname

    Remit Date

    DescriptionThe 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 BlockNote: 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 / SituationalSituational
    XML / JSON Fieldprimary_paid_date
    X12 Loop / SegmentN/A
    Allowed Valuesdate mmddyy
    Notes



    Fieldname

    Paid (Primary Paid Amount)

    DescriptionThe amount paid by the primary (or if tertiary claim, the secondary) payer.
    Paper Claim BlockNote: 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 / SituationalSituational
    XML / JSON Fieldprimary_paid_amount_2
    X12 Loop / Segment
    Allowed Valuesdate mmddyy
    Notes



    Professional Claim- Box 25-30
    Tax ID / Patient Acct # / Total Charge / Amount Paid / Balance


    Fieldname

    Federal Tax ID Number

    DescriptionThe Federal Tax Identification Number (TIN) of the billing provider or the facility.
    Paper Claim Block25
    Required / SituationalRequired for group or facility billing, Situational for individual providers
    XML / JSON Fieldbill_taxid
    X12 Loop / Segment Loop 2300 - CLM01
    Allowed Values16 characters
    NotesEIN 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

    DescriptionThe 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 Block26
    Required / SituationalRequired
    XML / JSON Fieldpcn
    X12 Loop / SegmentLoop 2300 - CLM07 
    Allowed Values1 character "YES" or "NO."
    NotesThis is either decided by the biller (usually following a convention) or generated from a PMS/EMR system


    Fieldname

    Accept Assignment

    DescriptionIndication 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 Block27
    Required / SituationalRequired
    XML / JSON Fieldaccept_assign
    X12 Loop / SegmentLoop 2300 - CLM07
    Allowed Values1 character "YES" or "NO."
    Notes


    Fieldname

    Total Charge

    DescriptionThe total charge for all services rendered to the patient.
    Paper Claim Block28
    Required / SituationalRequired
    XML / JSON Fieldtotal_charge
    X12 Loop / SegmentLoop 2300 - CLM02
    Allowed Values12.2
    Notes


    Fieldname

    Amount Paid

    DescriptionThe total amount paid by the primary payer.
    Paper Claim Block29
    Required / SituationalSituational
    XML / JSON Fieldamount_paid
    X12 Loop / SegmentLoop 2300 (patient amount paid) , 2320 (payer amount paid)  - AMT02
    Allowed ValuesNumeric 8.2
    Notes


    Fieldname

    Balance Due

    DescriptionThe amount remaining to be paid by the patient after considering the total charges, primary payer's payment, and any adjustments or deductions.
    Paper Claim Block30
    Required / SituationalSituational
    XML / JSON Fieldbalance_due
    X12 Loop / Segment
    Allowed Values
    Notes


    Professional Claim- Block 31
    Rendering Provider Information
    Fieldname

    Rendering Provider Last Name

    DescriptionThe last name or surname of the rendering healthcare provider who performed or provided the healthcare services.
    Paper Claim Block31
    Required / SituationalRequired
    XML / JSON Fieldprov_name_l
    X12 Loop / SegmentLoop 2310B - NM1
    Allowed Values35 characters
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Rendering Provider First Name

    DescriptionThe first name or given name of the rendering healthcare provider who performed or provided the healthcare services.
    Paper Claim Block31
    Required / SituationalRequired
    XML / JSON Fieldprov_name_f
    X12 Loop / SegmentLoop 2310B - NM1 (Name)
    Allowed Values25 characters
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Rendering Provider Middle Name

    DescriptionThe middle name or initial of the rendering healthcare provider who performed or provided the healthcare services.
    Paper Claim Block31
    Required / SituationalSituational
    XML / JSON Fieldprov_name_m
    X12 Loop / SegmentLoop 2310B - NM1 (Name)
    Allowed Values25 characters
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Rendering Provider NPI

    DescriptionThe National Provider Identifier (NPI) number assigned to the rendering healthcare provider.
    Paper Claim Block31
    Required / SituationalRequired
    XML / JSON Fieldprov_npi
    X12 Loop / SegmentLoop 2310B - NM1
    Allowed ValuesNumeric 10 characters digits representing the unique NPI number assigned to the rendering provider by the National Plan and Provider Enumeration System (NPPES).
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Rendering Provider Atypical ID

    DescriptionThe unique identification number or code assigned to the rendering healthcare provider by their practice or facility.
    Paper Claim BlockN/A (Not applicable as this field is not part of the standard CMS-1500 (02/12) paper claim form.)
    Required / SituationalSituational
    XML / JSON Field

    prov_id

    X12 Loop / SegmentN/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 Values32 characters
    NotesThe "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

    DescriptionThe name of the facility or location where the services were rendered.
    Paper Claim Block32
    Required / SituationalSituational
    XML / JSON Fieldfacility_name
    X12 Loop / SegmentLoop 2310C -NM103
    N403
    Allowed Values32 characters
    Notes


    Fieldname

    Service Facility Location Address

    DescriptionThe address of the facility or location where the services were rendered.
    Paper Claim Block32
    Required / SituationalSituational
    XML / JSON Fieldfacility_addr_1
    X12 Loop / SegmentLoop 2310E - N301
    Allowed Values64 characters
    Notes


    Fieldname

    Service Facility Location City

    Description The city where the facility or location is located.
    Paper Claim Block32
    Required / SituationalSituational
    XML / JSON Fieldfacility_city
    X12 Loop / Segment Loop 2310E - N401 
    Allowed Values32 characters
    Notes


    Fieldname

    Service Facility Location State

    Description The state where the facility or location is located.
    Paper Claim Block32
    Required / SituationalSituational
    XML / JSON Fieldfacility_state
    X12 Loop / SegmentLoop 2310E - N402
    Allowed Values Two-letter state codes (e.g., CA, NY, TX).
    Notes


    Fieldname

    Service Facility Location ZIP Code

    DescriptionThe ZIP code of the facility or location where the services were rendered.
    Paper Claim Block32
    Required / SituationalSituational
    XML / JSON Fieldfacility_zip
    X12 Loop / Segment Loop 2310E - N403 (Service Facility Location City, State, ZIP Code)
    Allowed Values12 characters
    Notes


    Fieldname

    Facility NPI

    DescriptionThe National Provider Identifier (NPI) number assigned to the facility or institution where the healthcare services were rendered or performed.
    Paper Claim Block32a
    Required / SituationalSituational (If applicable to the claim, the Facility NPI is required.)
    XML / JSON Fieldfacility_npi
    X12 Loop / SegmentLoop 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).
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search
    Fieldname

    Facility ID

    DescriptionThe unique identification number assigned to the facility or institution where the healthcare services were rendered or performed.
    Paper Claim Block32b
    Required / SituationalSituational (If applicable to the claim, the Facility ID is required.)
    XML / JSON Fieldfacility_id
    X12 Loop / SegmentLoop 2310C - REF01, REF02
    Allowed Values32 characters - Alphanumeric characters, spaces, and special characters representing the facility's unique identification number or code.
    NotesThe 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 

    DescriptionThe 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 Block33
    Required / SituationalRequired
    XML / JSON Fieldbill_name
    X12 Loop / SegmentLoop 2010AA - NM103
    Allowed Values32 characters
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Billing Provider Address

    DescriptionThe 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 Block33
    Required / SituationalRequired
    XML / JSON Fieldbill_addr_1
    X12 Loop / SegmentLoop 2010AA - N3 01
    Allowed Values128 characters
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Billing Provider City

    DescriptionThe city where the billing provider is located.
    Paper Claim Block33
    Required / SituationalRequired
    XML / JSON Fieldbill_city
    X12 Loop / SegmentLoop 2010AA - N4 01 (city)
    Allowed Values32 characters
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Billing Provider State 

    DescriptionThe state where the billing provider is located.
    Paper Claim Block33
    Required / SituationalRequired
    XML / JSON Fieldbill_state
    X12 Loop / SegmentLoop 2010AA - N4 02
    Allowed ValuesTwo-letter state codes (e.g., CA, NY, TX).
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Billing Provider ZIP Code

    DescriptionThe ZIP code of the billing provider's location.
    Paper Claim Block33
    Required / SituationalRequired
    XML / JSON Fieldbill_zip
    X12 Loop / SegmentLoop 2010AA - N4 03
    Allowed Values12 characters
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Billing Provider Phone Number

    Field not in claim form

    DescriptionThe phone number of the billing provider or the entity submitting the claim. This can include the area code.
    Paper Claim Block33
    Required / SituationalRequired
    XML / JSON Fieldbill_phone
    X12 Loop / SegmentLoop 2010AA - PER
    Allowed Values16 characters
    NotesNot on the electronic form. Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Billing Provider NPI

    DescriptionThe National Provider Identifier assigned to a healthcare provider for the purpose of processing and tracking medical claims.
    Paper Claim Block33a
    Required / SituationalRequired
    XML / JSON Fieldbill_npi
    X12 Loop / SegmentLoop 2010AA / NM1 09
    Allowed Values10 characters
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search


    Fieldname

    Billing Provider Taxonomy

    DescriptionThe code that specifies the type or classification of healthcare services provided by the billing provider.
    Paper Claim Block33b
    Required / SituationalSituational
    XML / JSON Fieldbill_taxonomy
    X12 Loop / SegmentLoop 2000A - PRV03 /  2010AA - REF01, REF02
    Allowed Values10 characters - representing the specific taxonomy code assigned to the billing provider by relevant healthcare authorities or organizations.
    NotesProvider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search



    Fieldname

    Billing Provider ID

    DescriptionThe unique identification number or code assigned to the billing healthcare provider or organization by their practice or facility.
    Paper Claim Block33b
    Required / SituationalSituational (Required if this is used instead of NPI)
    XML / JSON Fieldbill_id
    X12 Loop / SegmentLoop 2010BB, REF*G2
    Allowed Values32 characters
    NotesThe "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

    DescriptionThe information in this box must match the pay-to information that is being electronically billed.
    Paper Claim Block33
    Required / SituationalSituational
    XML / JSON Fieldpay_name
    X12 Loop / SegmentLoop 2010AB, NM1/87
    Allowed ValuesText 50
    Notes
    Fieldname

    Pay-To Provider Address

    DescriptionThe information in this box must match the pay-to information that is being electronically billed.
    Paper Claim Block33
    Required / SituationalSituational
    XML / JSON Fieldpay_addr_1, pay addr_2
    X12 Loop / SegmentLoop 2010AB, N3, 01, 02, 87
    Allowed ValuesText 55
    Notes
    Fieldname

    Pay-To Provider City

    DescriptionThe information in this box must match the pay-to information that is being electronically billed.
    Paper Claim Block33
    Required / SituationalSituational
    XML / JSON Fieldpay_city
    X12 Loop / SegmentLoop 2010AB, N4, 01, 87
    Allowed ValuesText 30
    Notes
    Fieldname

    Pay-To Provider State

    DescriptionThe information in this box must match the pay-to information that is being electronically billed.
    Paper Claim Block33
    Required / SituationalSituational
    XML / JSON Fieldpay_state
    X12 Loop / SegmentLoop 2010AB, N4, 02, 87
    Allowed ValuesText 2
    Notes
    Fieldname

    Pay-To Provider Zip

    DescriptionThe information in this box must match the pay-to information that is being electronically billed.
    Paper Claim Block33
    Required / SituationalSituational
    XML / JSON Fieldpay_zip
    X12 Loop / SegmentLoop 2010AB, N4, 03, 87
    Allowed ValuesText 12
    Notes
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