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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.
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.
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.
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
Supervisor Name / ID / NPI
Description
The name of the supervisor or overseeing healthcare professional who provided or supervised the healthcare services.
Paper Claim Block
N/A (Not applicable as this field is not part of the standard CMS-1500 (02/12) paper claim form.)
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.
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
Fieldname
CLIA Number
Description
Clinical Laboratory Improvement Amendments (CLIA) number assigned to the laboratory performing the tests.
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)
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.
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
The last name of the healthcare provider who performed the services or procedures.
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.
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.
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.
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.
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.
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).
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).
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.
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.
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
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