The electronic UB-04 form used in contemporary healthcare billing is based on the paper UB-04 form, which is an institutional claim form for submitting insurance claims. The Claim.MD online version of the UB-04 retains the familiar layout of the paper form while incorporating electronic elements supported in the ANSI X12 837I electronic claim standard, which is specific to institutional claims. This document provides a comprehensive description of each field on the UB-04 claim form and offers a correlation to their corresponding electronic components.
The paper version of the claim form (UB04) can be visually compared to identify the differences.
Claim.MD Facility Claim Form (as seen on the View/Edit Claims page)
Facility Claim- Block 1
Billing Provider Information
| Field Name | Billing Provider Name |
|---|
|
| Description | The name of the billing provider or the entity responsible for submitting the claim. This could be the name of a group practice or facility. |
| Paper Claim Block | 1 |
| Required / Situational | Situational |
| XML / JSON Field | bill_name |
| X12 Loop / Segment | 2010AA / NM103 |
| Allowed Values | 32 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Field Name | Billing Provider Address 1, Billing Provider Address 2 |
|---|
|
| Description | The address of the billing provider or the entity responsible for submitting the claim. |
| Paper Claim Block | 1 |
| Required / Situational | Required |
| XML / JSON Field | bill_addr_1, bill_addr_2 |
| X12 Loop / Segment | Loop 2010BB / N301 /N302 |
| Allowed Values | 128 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Field Name | Billing Provider City |
|---|
|
| Description | The city where the billing provider is located. |
| Paper Claim Block | 1 |
| Required / Situational | Required |
| XML / JSON Field | bill_city |
| X12 Loop / Segment | Loop 2010AA - NM401 |
| Allowed Values | 32 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Field Name | Billing Provider State |
|---|
|
| Description | The state where the billing provider is located. |
| Paper Claim Block | 1 |
| Required / Situational | Required |
| XML / JSON Field | bill_state |
| X12 Loop / Segment | Loop 2010AA - NM402 |
| Allowed Values | Two-letter state codes (e.g., CA, NY, TX). |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Field Name | Billing Provider Zip Code |
|---|
|
| Description | The ZIP code of the billing provider's location. |
| Paper Claim Block | 1 |
| Required / Situational | Required |
| XML / JSON Field | bill_zip |
| X12 Loop / Segment | Loop 2010AA - NM403 |
| Allowed Values | 12 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Field Name | Billing Provider Phone Number |
|---|
|
| Description | The phone number of the billing provider or the entity submitting the claim. This can include the area code. |
| Paper Claim Block | 1 |
| Required / Situational | Required |
| XML / JSON Field | bill_phone |
| X12 Loop / Segment | Loop 2010AA - PER04 |
| Allowed Values | 16 characters |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Field Name | Pay-To-Provider Address 1, Pay-To-Provider Address 2 |
|---|
|
| Description | This specifies the address of the provider or entity to whom payment should be directed for the services rendered. |
| Paper Claim Block | 1a (also 2) |
| Required / Situational | Situational |
| XML / JSON Field | pay_addr_1, pay_addr_2 |
| X12 Loop / Segment | Loop 2010AA- N301, N302 |
| Allowed Values | 55 characters |
| Notes |
|
| Field Name | Pay To Provider City |
|---|
|
| Description | This specifies the city of the provider or entity to whom payment should be directed for the services rendered. |
| Paper Claim Block | 1a (also 2) |
| Required / Situational | Situational |
| XML / JSON Field | pay_city |
| X12 Loop / Segment | Loop 2010AA- N401 |
| Allowed Values | 30 characters |
| Notes |
|
| Field Name | Pay To Provider State |
|---|
|
| Description | This specifies the city of the provider or entity to whom payment should be directed for the services rendered. |
| Paper Claim Block | 1a (also 2) |
| Required / Situational | Situational |
| XML / JSON Field | pay_state |
| X12 Loop / Segment | Loop 2010AA- N402 |
| Allowed Values | 2 characters |
| Notes |
|
| Field Name | Pay To Provider Zip Code |
|---|
|
| Description | This specifies the zip code of the provider or entity to whom payment should be directed for the services rendered. |
| Paper Claim Block | 1a (also 2) |
| Required / Situational | Situational |
| XML / JSON Field | pay_zip |
| X12 Loop / Segment | Loop 2010AA- N403 |
| Allowed Values | 12 characters |
| Notes |
|
| Field Name | Facility Name |
|---|
|
| Description | This specifies the name of the facility where the services were provided to the patient. |
| Paper Claim Block | 1b |
| Required / Situational | Situational |
| XML / JSON Field | facility_name |
| X12 Loop / Segment | Loop 2010AB- NM103 |
| Allowed Values | 32 characters |
| Notes |
|
| Field Name | Facility Address, Facility Address 2 |
|---|
|
| Description | This specifies the address of the facility where the services were provided to the patient. |
| Paper Claim Block | 1b |
| Required / Situational | Situational |
| XML / JSON Field | facility_addr_1, facility_addr_2 |
| X12 Loop / Segment | Loop 2010AB-N301, N302 |
| Allowed Values | 64 characters |
| Notes |
|
| Field Name | Facility City |
|---|
|
| Description | This specifies the city of the facility where the services were provided to the patient. |
| Paper Claim Block | 1b |
| Required / Situational | Situational |
| XML / JSON Field | facility_city |
| X12 Loop / Segment | Loop 2010AA- N401 |
| Allowed Values | 32 characters |
| Notes |
|
| Field Name | Facility State |
|---|
|
| Description | This specifies the state of the facility where the services were provided to the patient. |
| Paper Claim Block | 1b |
| Required / Situational | Situational |
| XML / JSON Field | facility_state |
| X12 Loop / Segment | Loop 2010AA- N402 |
| Allowed Values | 2 characters |
| Notes |
|
| Field Name | Facility Zip Code |
|---|
|
| Description | This specifies the zip code of the facility where the services were provided to the patient. |
| Paper Claim Block | 1b |
| Required / Situational | Situational |
| XML / JSON Field | facility_zip |
| X12 Loop / Segment | Loop 2010AA- N403 |
| Allowed Values | 12 characters |
| Notes |
|
| Field Name | Facility NPI |
|---|
|
| Description | This specifies the NPI of the facility where the services were provided to the patient. |
| Paper Claim Block | 1b |
| Required / Situational | Situational |
| XML / JSON Field | facility_npi |
| X12 Loop / Segment | Loop 2010AA-REF02 |
| Allowed Values | 12 characters |
| Notes |
|
Facility Claim- Block 2-9
Patient Control Number, Medical Record Number, Type of Bill, Fed. Tax No, Statement From-Thru, Patient Information
| Field Name | PCN (Patient Control Number) |
|---|
|
| Description | This field is used to capture a unique identifier assigned by the provider to the patient. It is often utilized to link the claim information to the patient's records within the provider's system, allowing for better tracking and management of healthcare services and billing. |
| Paper Claim Block | 3a |
| Required / Situational | Required |
| XML / JSON Field | pcn |
| X12 Loop / Segment | Loop 2300 - CLM01 |
| Allowed Values | 32 characters |
| Notes | This is either decided by the biller (usually following a convention) or generated from a PMS/EMR system. |
| Field Name | MRN (Medical Record Number) |
|---|
|
| Description | This captures the patient's unique identification number within the healthcare provider's system. While the PCN is specifically to link the patient to claim information, the MRN often links the patient information to their medical history. |
| Paper Claim Block | 3b |
| Required / Situational | Situational |
| XML / JSON Field | mrn |
| X12 Loop / Segment | Loop 2300- REF02 |
| Allowed Values | 32 characters |
| Notes |
|
| Field Name | Type of Bill (NUBC Type of Bill) |
|---|
|
| Description | The "Type of Bill" code identifies the specific category or type of service for which the claim is being submitted. This code helps the payer categorize and process the claim correctly. The "Type of Bill" code is essential for determining the appropriate payment and adjudication processes for the submitted claim. |
| Paper Claim Block | 4 |
| Required / Situational | Required |
| XML / JSON Field | type_of_bill |
| X12 Loop / Segment | 2300 - CLM05-1 (Value 11 – Inpatient, 13 –Outpatient, or 18 – Critical Access Hospitals/Swing Beds for Sub-Acute Care) CLM05-2 (Value A – Uniform Billing Claim Form Bill Type) CLM05-3 (Value 1 – Original Bill, 7 –Request for Adjustment, or 8 – Request for Void of Previous Bill) |
| Allowed Values | 3 characters |
| Notes |
|
| Field Name | Billing Provider Tax ID (EIN) |
|---|
|
| Description | This block is used to provide the federal tax identification number (TIN) of the billing entity or provider. |
| Paper Claim Block | 5 |
| Required / Situational | Required |
| XML / JSON Field | bill_taxid |
| X12 Loop / Segment | Loop 2010AA - REF01 (Value EI – Employer ID) REF02 (Tax ID) |
| Allowed Values | 16 characters |
| Notes |
|
| Field Name | Statement From Date, Statement Thru Date |
|---|
|
| Description | This is used to indicate the start and end dates of the billing period for the services being claimed. |
| Paper Claim Block | 6 |
| Required / Situational | Required |
| XML / JSON Field | fdos, ldos |
| X12 Loop / Segment | Loop 2300 - DTP01 (Qualifier 434 – Statement) DTP02 (Value D8, Format: CCYYMMDD or RD8 – Date Range) DTP03 (Date or Dates) |
| Allowed Values | Date yyyymmdd |
| Notes |
|
>
Field name not displayed| Field Name | Reserved for Assignment by the NUBC |
|---|
|
|
|
|
| Description | N/A |
| Paper Claim Block | 7 |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | N/A |
| Allowed Values | N/A |
| Notes |
|
| Field Name | Patient Name (Last, First, Middle initial) |
|---|
|
| Description |
|
| Paper Claim Block | 8 |
| Required / Situational | last name and first name required |
| XML / JSON Field | pat_name_l, pat_name_f, pat_name_m |
| X12 Loop / Segment | Loop 2010BA if 2010CA is not sent - NM103 (Last Name), NM104 (First Name), NM105 (Middle Name) |
| Allowed Values | 35 characters (last name), 25 characters (first name), 25 characters (middle initial) |
| Notes |
|
| Field Name | Patient Address, Patient Address 2 |
|---|
|
| Description | This captures the street address of the patient for communication and identification purposes. |
| Paper Claim Block | 9 |
| Required / Situational | Required (Address 1 only) |
| XML / JSON Field | pat_addr_1, pat_addr_2 |
| X12 Loop / Segment | Loop 2010BA if 2010CA is not sent - N301 |
| Allowed Values | 55 characters |
| Notes |
|
| Field Name | Patient City |
|---|
|
| Description | This captures the city residence of the patient for communication and identification purposes. |
| Paper Claim Block | 9 |
| Required / Situational | Required |
| XML / JSON Field | pat_city |
| X12 Loop / Segment | Loop 2010BA if 2010CA is not sent - N401 |
| Allowed Values | 30 characters |
| Notes |
|
| Field Name | Patient State |
|---|
|
| Description | This captures the state residence of the patient for communication and identification purposes. |
| Paper Claim Block | 9 |
| Required / Situational | Required |
| XML / JSON Field | pat_state |
| X12 Loop / Segment | Loop 2010BA if 2010CA is not sent - N402 |
| Allowed Values | 2 characters |
| Notes |
|
| Field Name | Patient Zip Code |
|---|
|
| Description | This captures the zip code residence of the patient for communication and identification purposes. |
| Paper Claim Block | 9 |
| Required / Situational | Required |
| XML / JSON Field | pat_zip |
| X12 Loop / Segment | Loop 2010BA if 2010CA is not sent - N403 |
| Allowed Values | 15 characters |
| Notes |
|
| Field Name | Patient Country Code |
|---|
|
| Description | This captures the country of the patient for communication and identification purposes. |
| Paper Claim Block | 9 |
| Required / Situational | Required |
| XML / JSON Field | pat_country |
| X12 Loop / Segment | Loop 2010BA if 2010CA is not sent - N404 |
| Allowed Values | 2 characters |
| Notes |
|
Facility Claim- Block 10-17
Patient Information, Admit & Discharge Information
| Field Name | Patient Date of Birth |
|---|
|
| Description | This is used to capture the "Birthdate" of the patient, providing essential demographic information for healthcare identification and record-keeping. |
| Paper Claim Block | 10 |
| Required / Situational | Required |
| XML / JSON Field | pat_dob |
| X12 Loop / Segment | Loop 2010BA if 2010CA is not sent - DMG01 (Value D8 – Format:CCYYMMDD), DMG02 (Birthdate) |
| Allowed Values | 10 characters |
| Notes |
|
| Field Name | Patient Gender |
|---|
|
| Description | Used to indicate the gender of the patient, aiding in accurate patient identification and healthcare record management. |
| Paper Claim Block | 11 |
| Required / Situational | Required |
| XML / JSON Field | pat_sex |
| X12 Loop / Segment | Loop 2010BA if 2010CA is not sent - DMG03 (Value M – Male, F – Female or U – Unknown) |
| Allowed Values | 1 character (M/F/U |
| Notes |
|
| Field Name | Admitting Date |
|---|
|
| Description | Refers to the date when a patient was admitted to the healthcare facility for treatment or services, providing critical information for billing and claims processing. |
| Paper Claim Block | 12 |
| Required / Situational | Required |
| XML / JSON Field | hosp_from_date |
| X12 Loop / Segment | Loop 2300 - DTP01 (Qualifier 435 – Statement), DTP02 (Value D8 – Format: CCYYMMDD or DT – Format CCYYMMDDHHMM), DTP 03 (Single Date or Date Range) |
| Allowed Values | Date yyyymmdd |
| Notes |
|
| Field Name | Admitting Hour 00-24 |
|---|
|
| Description | Captures the hour at which a patient was admitted to the healthcare facility, providing a more detailed timestamp for admission information on the claim form. |
| Paper Claim Block | 13 |
| Required / Situational | Required |
| XML / JSON Field | admit_hour |
| X12 Loop / Segment | Loop 2300 - DTP01 (Qualifier 435 – Statement), DTP02 (Value D8 – Format: CCYYMMDD or DT – Format CCYYMMDDHHMM), DTP 03 (Single Date or Date Range) |
| Allowed Values | Numeric 2.0 |
| Notes |
|
| Field Name | Admitting Hour 00-24 |
|---|
|
| Description | Captures the hour at which a patient was admitted to the healthcare facility, providing a more detailed timestamp for admission information on the claim form. |
| Paper Claim Block | 13 |
| Required / Situational | Required |
| XML / JSON Field | admit_hour |
| X12 Loop / Segment | Loop 2300 - DTP01 (Qualifier 435 – Statement), DTP02 (Value D8 – Format: CCYYMMDD or DT – Format CCYYMMDDHHMM), DTP 03 (Single Date or Date Range) |
| Allowed Values | Numeric 2.0 |
| Notes |
|
| Field Name | Admit Type |
|---|
|
| Description | Captures the category or reason for a patient's admission to a healthcare facility, such as emergency, elective, newborn, etc., providing important contextual information for billing and patient care. |
| Paper Claim Block | 14 |
| Required / Situational | Required |
| XML / JSON Field | admit_type |
| X12 Loop / Segment | Loop 2300 - CL101 |
| Allowed Values | 1 character |
| Notes |
|
| Field Name | Admit Source |
|---|
|
| Description | Captures the hour at which a patient was admitted to the healthcare facility, providing a more detailed timestamp for admission information on the claim form. |
| Paper Claim Block | 13 |
| Required / Situational | Required |
| XML / JSON Field | admit_source |
| X12 Loop / Segment | Loop 2300 - CL102 |
| Allowed Values | 1 character |
| Notes |
|
| Field Name | Discharge Hour 00-24 |
|---|
|
| Description | Captures the hour at which a patient was admitted to the healthcare facility, providing a more detailed timestamp for admission information on the claim form. |
| Paper Claim Block | 16 |
| Required / Situational | Required |
| XML / JSON Field | disch_hour |
| X12 Loop / Segment | DTP01 (Qualifier 096 – Discharge), DTP02 (Value TM – Format HHMM), DTP 03 (Time)
|
| Allowed Values | Numeric 2.0 |
| Notes |
|
| Field Name | Discharge Status |
|---|
|
| Description | Discharge status in healthcare refers to the condition under which a patient leaves a healthcare facility. It indicates the patient's health status at the time of discharge and provides important information for care coordination, billing, and post-hospitalization planning. |
| Paper Claim Block | 17 |
| Required / Situational | Required |
| XML / JSON Field | disch_status |
| X12 Loop / Segment | CL103 (Status Code) |
| Allowed Values | Numeric 2.0 |
| Notes | 2 characters |
Facility Claim- Block 18-41
Condition Codes, Occurrence Codes, Value Codes
| Field Name | Condition Codes |
|---|
|
| Description | A "Condition Code" is a numerical identifier used to convey specific situations, such as a patient's urgent admission (code 17), or patient's admission for observation (code 41), during their healthcare facility stay, aiding in accurate billing and claims processing. |
| Paper Claim Block | 18-28 |
| Required / Situational | Situational |
| XML / JSON Field | cond_code_1 |
| X12 Loop / Segment | Loop 2300 - HI01-1 (Value BG – Condition), HI01-2 (Condition Code) |
| Allowed Values | 2 characters |
| Notes |
|
| Field Name | ACDT State |
|---|
|
| Field not displayed on form |
| Description | Refers to the state where the "Accident Date" (ACDT) occurred, which is the date when an accident or injury leading to the patient's medical condition took place. It aids in accurate billing, claims processing, and documentation of the circumstances surrounding the patient's condition. |
| Paper Claim Block | 29 |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | Loop 2300 - HI01-1 (Value BG – Condition), HI01-2 (Condition Code) |
| Allowed Values | 2 characters |
| Notes |
|
| Field Name | Reserved for Assignment by NUBC |
|---|
|
| Field not displayed on form |
|
| Description | N/A |
| Paper Claim Block | 30 |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | N/A |
| Allowed Values | N/A |
| Notes |
|
| Field Name | Occurrence Code 1-8; Occurrence Date 1-8 |
|---|
|
| Description | "Occurrence Code" is a numerical identifier used to convey specific events or circumstances during a patient's stay, such as reporting an occurrence of a significant event (code 25) or a date of the last menstrual period (code 50), aiding in accurate billing and claims processing. |
| Paper Claim Block | 31-36 |
| Required / Situational | Situational |
| XML / JSON Field | occ_code_1, occ_code_2, occ_code_3, occ_code_4, occ_code_5, occ_code_6, occ_code_7, occ_code_8
occ_date_1_date, occ_date_2_date, occ_date_3_date, occ_date_4_date, occ_date_5_date, occ_date_6_date, occ_date_7_date, occ_date_8_date |
| X12 Loop / Segment | HI01-1 (Value BH – Occurrence), HI01-2 (Occurrence Code – see notes), HI01-3 (Value D8 – Format: CCYYMMDD), HI01-4 (Date) |
| Allowed Values | 2 characters (Occurrence Code), Date yyyymmdd (Occurrence Date) |
| Notes |
|
| Field Name | Reserved for Assignment by NUBC |
|---|
|
| Field not displayed on form |
|
| Description | N/A |
| Paper Claim Block | 37 |
| Required / Situational | N/A |
| XML / JSON Field | N/A |
| X12 Loop / Segment | N/A |
| Allowed Values | N/A |
| Notes |
|
Field not displayed in Claim.MD form
| Field Name | Responsible Party Name/Address |
|---|
|
| Description | Refers to the identification and contact information of the individual or entity responsible for the patient's medical expenses, enabling accurate communication, billing, and claims processing for the party responsible for covering the incurred healthcare costs. |
| Paper Claim Block | 38 |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | 2000B - SBR01 (Value P – Primary), SBR09 (Value WC – Worker’s Comp) |
| Allowed Values | N/A |
| Notes |
|
| Field Name | Value Codes / Value Amount |
|---|
|
| Description | "Value Code and Amount" is a numeric code and corresponding monetary amount used to provide additional information about specific aspects of a patient's care, such as reporting the amount of covered days in skilled nursing (code 80) or the purchase price of a piece of durable medical equipment (code 77), aiding in accurate billing and claims processing. |
| Paper Claim Block | 39-41 |
| Required / Situational | Situational |
| XML / JSON Field | value_code_1, value_code_2, value_code_3, value_code_4, value_code_5, value_code_6, value_code_7, value_code_8
value_amt_1, value_amt_2, value_amt_3, value_amt_4, value_amt_5, value_amt_6, value_amt_7, value_amt_8 |
| X12 Loop / Segment | Loop 2300 - HI01-1 (Value BE – Value Code), HI01-2 (Value Code), HI01-5 (Amount) |
| Allowed Values | 2 characters (Value |
| Notes |
|
Facility Claim- Block 42-48
Rev Code, HCPC, Charges, NDC
| Field Name | Revenue Code |
|---|
|
| Description | A "Revenue Code" is a numerical code used to classify specific healthcare services or items provided to a patient, such as inpatient room and board (code 100), pharmacy services (code 250), or laboratory services (code 300), helping in accurate billing and categorization of services on the UB-04 claim form. |
| Paper Claim Block | 42 |
| Required / Situational | Required |
| XML / JSON Field | rev_code |
| X12 Loop / Segment | Loop 2400 - SV201 (Service Line Revenue Code) |
| Allowed Values | 5 characters |
| Notes | Refer to the NUBC UB-04 Data Specifications Manual for specific code references |
| Field Name | HCPC Description (Additional Narrative) |
|---|
|
| Description | Revenue Description/I DE Number/Medicaid Drug Rebate/ Line Level Rendering Provider NPI. |
| Paper Claim Block | 43 |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | Loop 2400 - SV202-7 (Description) |
| Allowed Values | N/A |
| Notes | Refer to the NUBC UB-04 Data Specifications Manual for specific code references |
| Field Name | HCPC (procedure codes) |
|---|
|
| Description | HCPC in Block 44 of the UB-04 claim form involve reporting specific medical procedures or services, such as "99213" for an outpatient office visit,. |
| Paper Claim Block | 44 |
| Required / Situational | Required |
| XML / JSON Field | proc_code |
| X12 Loop / Segment | SV202-1 (Value HC – HCPCS or HP –HIPPS), SV202-2 (Procedure Code) |
| Notes | CPT Codes references: |
| Field Name | Accommodation Rate Amount |
|---|
|
| Description | Block 44 on the UB-04 claim form involves reporting the "Accommodation Rate," which pertains to the rate associated specifically with a room and board revenue code, aiding in accurate billing and claims processing. |
| Paper Claim Block | 44 |
| Required / Situational | Situational |
| XML / JSON Field | SV202-1 (Value HC – HCPCS or HP –HIPPS), SV202-2 (Procedure Code) |
| X12 Loop / Segment | rate |
| Allowed Values | Numeric 8.2 |
| Notes | Refer to the NUBC UB-04 Data Specifications Manual for specific code references |
| Field Name | Modifiers |
|---|
|
| Description | HCPCS modifiers are two-character codes appended to procedure codes to convey specific details about a healthcare service, such as "-GT" for telehealth services, enhancing accurate billing and claims processing. |
| Paper Claim Block | 44 |
| Required / Situational | Situational |
| XML / JSON Field | mod1, mod2, mod3, mod4 |
| X12 Loop / Segment | SV202-3 through SV202-6 (Modifiers) |
| Allowed Values | 2 characters |
| Notes |
|
| Field Name | Service Date |
|---|
|
| Description | "Dates of Service," is the date when services were first provided. |
| Paper Claim Block | 45 |
| Required / Situational | Required |
| XML / JSON Field | from_date |
| X12 Loop / Segment | Loop 2400 - DTP01 (Value 472 – Service date), DTP02 (Value D8 – Format:, CCYYMMDD or RD8 – Date Range)DTP03 (Date or Dates) |
| Allowed Values | Date yyyymmdd |
| Notes |
|
| Field Name | Units (Service Units) |
|---|
|
| Description | This captures the quantity of healthcare services provided, such as "5" for inpatient days or "3" for outpatient visits, crucial for precise billing and claims processing. |
| Paper Claim Block | 46 |
| Required / Situational | Required |
| XML / JSON Field | units |
| X12 Loop / Segment | Loop 2400 - SV204 (Value DA – Days or UN –Units), SV205 (Service Unit Count) |
| Allowed Values | (dropdown UN/DA) and 6 characters for number of units |
| Notes |
|
| Field Name | Charge Amount |
|---|
|
| Description | This field is used for reporting the specific charge associated with the specific service provided, ensuring accurate billing and claims processing. |
| Paper Claim Block | 47 |
| Required / Situational | Required |
| XML / JSON Field | charge |
| X12 Loop / Segment | Loop 2400 - SV203 (Line item charge amount) |
| Allowed Values | Numeric 9.2 |
| Notes |
|
| Field Name | COB Non-Covered Amount |
|---|
|
| Description | "Non-covered charges" refer to healthcare services or items that are not eligible for reimbursement or coverage by an insurance plan or payer, requiring patients to bear the financial responsibility for those specific expenses. |
| Paper Claim Block | 48 |
| Required / Situational | Situational |
| XML / JSON Field | total_non_covered |
| X12 Loop / Segment | Loop 2400- SV207 (Line Item Denied Charge or Non-Covered Charge Amount) |
| Allowed Values | Numeric 10.2 |
| Notes |
|
| Field Name | Total Charge Amount |
|---|
|
| Description | The "Total Charge Amount" represents the sum of all charges associated with the healthcare services provided to a patient, reflecting the full cost of care before any adjustments, discounts, or insurance payments are applied. |
| Paper Claim Block | 47 |
| Required / Situational | Required |
| XML / JSON Field | total_charge |
| X12 Loop / Segment | Loop 2400 - SV203 (Line item charge amount) |
| Allowed Values | Numeric 12.2 |
| Notes | This field will automatically add up all the charges in the individual charge lines for the specific procedures/services. |
| Field Name | NDC Code / Dosage / Measure |
|---|
|
| Description | NDC (National Drug Code) is a standardized numeric identifier used to uniquely identify pharmaceutical products for accurate tracking, documentation, and billing in the healthcare system.
The NDC (National Drug Code) dosage and measure refer to the specific dosage strength and measurement unit associated with a pharmaceutical product identified by its NDC code, aiding in accurate prescription and administration of medications. |
| Paper Claim Block | N/A *under block 47 |
| Required / Situational | Situational |
| XML / JSON Field | ndc_code, ndc_dosage, ndc_measure |
| X12 Loop / Segment | N/A |
| Allowed Values | 11 characters (code) 7 characters (dosage), 2 (measure) |
| Notes | NDC Code References:
http://www.accessdata.fda.gov/
https://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=ndc |
Facility Claim- Block 49-57
Payer Information, Relationship, Est. AMount Due, NPI, Taxonomy
| Field Name | Reserved for Assignment by NUBC |
|---|
|
| Field not displayed on form |
|
| Description | This is intended for future use or designation by the National Uniform Billing Committee (NUBC), which is responsible for maintaining and revising the UB-04 claim form and associated standards. |
| Paper Claim Block | N/A |
| Required / Situational | N/A |
| XML / JSON Field | N/A |
| X12 Loop / Segment | N/A |
| Allowed Values | N/A |
| Notes | See the NUBC guide |
| Field Name | Payer Name |
|---|
|
| Description | Refers to the name of the entity responsible for providing insurance coverage or making payments for healthcare services, enabling proper identification and communication in the claims and billing process. |
| Paper Claim Block | 50a |
| Required / Situational | Required |
| XML / JSON Field | payer_name |
| X12 Loop / Segment | 2010BB -NM101 (Value PR – Payer), NM102 (Value 2 – Non-person), NM103 (Payer Name) |
| Allowed Values | 64 characters |
| Notes |
|
| Field Name | Payer ID |
|---|
|
| Description | The unique identifier assigned to an insurance company or payer, used to accurately route and process healthcare claims, ensuring efficient communication and reimbursement between healthcare providers and payers. |
| Paper Claim Block | 51a |
| Required / Situational | Required |
| XML / JSON Field | payerid |
| X12 Loop / Segment | 2010BB - NM108 (Value PI – Payer ID), NM109 (NDWSI) |
| 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 |
| 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 | 50b |
| 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 | 51b |
| 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. |
| Field Name | Release of Information |
|---|
|
| Description | Refers to the patient's consent or authorization to allow their medical information to be shared with authorized parties, such as healthcare providers and insurance companies, for purposes of billing, claims processing, and other healthcare-related activities. |
| Paper Claim Block | 52 |
| Required / Situational | Situational |
| XML / JSON Field |
|
| X12 Loop / Segment | 2300 - Information 2300 CLM09 |
| Allowed Values | dropdown (Yes, signed or Informed Consent) |
| Notes |
|
| Field Name | Assignment of Benefits |
|---|
|
| Description | This indicates whether the healthcare provider agrees to accept the insurance payment as full reimbursement for covered services, alleviating the patient from any additional financial responsibility beyond their deductible, copayment, or coinsurance. |
| Paper Claim Block | 53 |
| Required / Situational | Required |
| XML / JSON Field | accept_assign |
| X12 Loop / Segment | Loop 2300 - CLM07 (Value A – Assigned), CLM08 (Value Y – Yes) |
| Allowed Values | 1 character (Y/N) |
| Notes |
|
| Field Name | Prior Payments |
|---|
|
| Field not displayed on form |
| Description | Indicates that the healthcare provider acknowledges any previous payments made by the patient or other sources toward the billed services, helping to ensure accurate billing and claims processing. |
| Paper Claim Block | 54 |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | Loop 2300 - AMT01 (Value C4 – Prior Payment). AMT02 (Amount) |
| Allowed Values | N/A |
| Notes |
|
| Field Name | Estimated Amount Due |
|---|
|
| Description | Refers to the projected or anticipated sum that the patient is expected to pay for healthcare services after accounting for insurance coverage, deductibles, coinsurance, and any previous payments, helping patients understand their financial responsibility and facilitating transparent billing practices. |
| Paper Claim Block | 55 |
| Required / Situational | Situational |
| XML / JSON Field |
|
| X12 Loop / Segment | Loop 2300 AMT01 (Value C5 – Claim Amount Due Estimated), AMT02 (Amount) |
| Allowed Values |
|
| Notes |
|
| Field Name | NPI |
|---|
|
| Description | This is used to report the "National Provider Identifier" (NPI) of the Billing Provider. The Billing Provider (2010AA) for Facility Claim Form Box 56 identifies the provider or entity responsible for billing the claim |
| Paper Claim Block | 56 |
| Required / Situational | Required |
| XML / JSON Field | prov2_npi |
| X12 Loop / Segment | 2010AA - NM108 (Value XX), NM109 (NPI) |
| Allowed Values | 10 numeric |
| Notes | Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search |
| Field Name | Taxonomy (or Other Prvoider ID) |
|---|
|
| Description | Designated for reporting the "Healthcare Provider Taxonomy Code" associated with the attending physician or non-physician practitioner, which classifies their specific healthcare specialty or profession, aiding in accurate identification and categorization of the provider for billing and claims processing.
It can also be designated as an additional identifier used to uniquely identify a healthcare provider. This identifier can be different from the primary identifier (such as the National Provider Identifier or NPI) and is often used for specific purposes, such as cross-referencing with other systems, tracking purposes, or billing and claims processing. It helps ensure accurate and efficient communication between healthcare entities and payers. |
| Paper Claim Block | 57 |
| Required / Situational | Situational |
| XML / JSON Field | prov2_taxonomy |
| X12 Loop / Segment | 2010AA - NM108 (Value XX), NM109 (NPI) |
| Allowed Values | 10 characters |
| Notes |
|
Facility Claim- Block 58-62
Insured's Information
| Field Name | Insured's Name (Last Name, First Name, Middle Name) |
|---|
|
| Description | Refers to the name of the individual covered by the insurance plan, facilitating accurate identification and claims processing. |
| Paper Claim Block | 58 |
| Required / Situational | Situational |
| XML / JSON Field | ins_name_l, ins_name_f, ins_name_m |
| X12 Loop / Segment | 2010BA -NM101 (Value IL – Insured), NM102 (Value 1 – Person or 2 –Organization), NM103 (Organization or Last Name), NM104 (First Name), NM105 (Middle Name) |
| Allowed Values | 35 characters (last name), 25 characters (first name), 25 characters (middle) |
| Notes |
|
| Field Name | Patient Relationship |
|---|
|
| Description | Designated for reporting the "Healthcare Provider Taxonomy Code" associated with the attending physician or non-physician practitioner, which classifies their specific healthcare specialty or profession, aiding in accurate identification and categorization of the provider for billing and claims processing. |
| Paper Claim Block | 59 |
| Required / Situational | Required |
| XML / JSON Field | pat_rel |
| X12 Loop / Segment | 2000B - SBR02 (Value 18 – Self or 20 – Workers’ Comp) |
| Allowed Values | 2 characters (dropdown) |
| Notes |
|
| Field Name | Insured ID (Policy Number) |
|---|
|
| Description | Refers to the unique identifier associated with the insured individual, aiding in accurate identification and claims processing. |
| Paper Claim Block | 60 |
| Required / Situational | Required |
| XML / JSON Field | ins_number |
| X12 Loop / Segment | 2010BA Or 2010CA - NM108 (Value MI – Member ID), NM109 (WSI Claim Number) Or REF01 (Value Y4 – Claim), REF02 (WSI Claim Number) |
| Allowed Values | 32 characters |
| Notes |
|
| Field Name | Insured Group Name |
|---|
|
| Description | Refers to the name of the insurance group or plan associated with the insured individual, aiding in accurate identification and claims processing. |
| Paper Claim Block | 61 |
| Required / Situational | Situational |
| XML / JSON Field | ins_plan |
| X12 Loop / Segment | 2000B - SBR04 |
| Allowed Values | 30 characters |
| Notes |
|
| Field Name | Insured Group Number |
|---|
|
| Description | This is used to report the "Insured's Group Number," which refers to the specific identification number assigned to the insurance group or plan associated with the insured individual, aiding in accurate identification and claims processing. |
| Paper Claim Block | 62 |
| Required / Situational | Situational |
| XML / JSON Field | ins_group |
| X12 Loop / Segment | 2000B - SBR03 |
| Allowed Values | 30 characters |
| Notes |
|
| Field Name | Payer Address 1, Payer Address 2 |
|---|
|
| Description | This refers to the physical location where the insurance company or payer is located, crucial for accurate communication, billing, and claims processing in healthcare. |
| Paper Claim Block | Under block 58 when "Show Payer Address" is checked |
| Required / Situational | Situational |
| XML / JSON Field | payer_addr_1, payer_addr_2 |
| X12 Loop / Segment | N/A |
| Allowed Values | 55 characters |
| Notes |
|
| Field Name | Payer City |
|---|
|
| Description | This is where the insurance company or payer is located, providing essential location information for accurate communication, billing, and claims processing in healthcare. |
| Paper Claim Block | N/A |
| Required / Situational | Situational |
| XML / JSON Field | payer_city |
| X12 Loop / Segment | N/A |
| Allowed Values | 30 characters |
| Notes |
|
| Field Name | Payer State |
|---|
|
| Description | This is the state where the insurance company or payer is located, playing a vital role in accurate communication, geographic identification, billing, and claims processing in healthcare. |
| Paper Claim Block | Under block 58 when "Show Payer Address" is checked |
| Required / Situational | Situational |
| XML / JSON Field | payer_state |
| X12 Loop / Segment | N/A |
| Allowed Values | 2 characters |
| Notes |
|
| Field Name | Payer Zip |
|---|
|
| Description | This refers to the postal code associated with the location of the insurance company or payer, which is crucial for precise communication, geographic identification, billing, and claims processing in the healthcare industry. |
| Paper Claim Block | Under block 58 when "Show Payer Address" is checked |
| Required / Situational | Situational |
| XML / JSON Field | payer_zip |
| X12 Loop / Segment | N/A |
| Allowed Values | 15 characters |
| Notes |
|
| Field Name | Payer Country |
|---|
|
| Description | This represents the internationally recognized two-letter code that identifies the specific country associated with the payer's location, enabling accurate geographical referencing for communication, billing, and claims processing in the healthcare context. |
| Paper Claim Block | Under block 58 when "Show Payer Address" is checked |
| Required / Situational | Situational |
| XML / JSON Field | pay_country |
| X12 Loop / Segment | N/A |
| Allowed Values | 2 characters |
| Notes |
|
Facility Claim- Block 63-73
Treatment Authorization Code, Document Control Number, DX & POA Information
| Field Name | Treatment Authorization Code |
|---|
|
| Description | This is a unique identifier assigned to authorize and track specific healthcare services or treatments, ensuring proper communication, documentation, and claims processing between healthcare providers and payers. |
| Paper Claim Block | 63 |
| Required / Situational | Situational |
| XML / JSON Field | auth_code_1 |
| X12 Loop / Segment | 2300 - REF01 (Value D9 – Document Control Number), REF02 (Unique Document Number) |
| Allowed Values | 32 characters |
| Notes |
|
| Field Name | Document Control Number (ICN/DCN) |
|---|
|
| Description | This is a unique identifier assigned to a specific document, such as a claim or medical record, to facilitate organization, tracking, and reference, aiding in efficient document management and accurate healthcare processes. |
| Paper Claim Block | 64 |
| Required / Situational | Situational |
| XML / JSON Field | icn_dcn_1 |
| X12 Loop / Segment | 2300 - REF01 (Value D9 – Document Control Number), REF02 (Unique Document Number) |
| Allowed Values | 32 characters |
| Notes |
|
| Field Name | Employer Name |
|---|
|
| Description | This represents the internationally recognized two-letter code that identifies the specific country associated with the payer's location, enabling accurate geographical referencing for communication, billing, and claims processing in the healthcare context. |
| Paper Claim Block | Under block 58 when "Show Payer Address" is checked |
| Required / Situational | Situational |
| XML / JSON Field | ins_employer |
| X12 Loop / Segment | 2010BA - NM101 (Value IL – Insured), NM102 (Value 2 – Organization), NM103 (Organization) |
| Allowed Values | 32 characters |
| Notes |
|
| Field Name | Diagnosis Code Qualifier A-L, Present on Admission A-L |
|---|
|
| Description | "Diagnosis Code Qualifier" refers to a code that indicates the type of diagnosis code being reported, such as "ICD" for International Classification of Diseases, aiding in accurate identification and categorization of medical conditions for billing and claims processing in healthcare.
"Principal Diagnosis Code and Present on Admission (POA) Indicator" involves reporting the primary diagnosis code for the patient's condition along with an indicator that specifies whether the condition was present upon admission to the healthcare facility, crucial for accurate billing and claims processing, and assessment of hospital-acquired conditions. |
| Paper Claim Block | 66 and 67 |
| Required / Situational | Situational |
| XML / JSON Field | diag_1, diag_2, diag_3, diag_4, diag_5, diag_6, diag_7, diag_8, diag_9, diag_10, diag_11, diag_12
diag_1_poa, diag_2_poa, diag_3_poa, diag_4_poa, diag_5_poa, diag_6_poa, diag_7_poa, diag_8_poa, diag_9_poa, diag_10_poa, diag_11_poa, diag_12_poa |
| X12 Loop / Segment | Loop 2300+ HI01-1 (Value ABK - ICD10)
Loop 2300 HI01-1 (Value ABK – ICD10), HI01-2 (Code), HI01-9 (Value Y – Yes, N – No, U – Unknown, or W – Not Applicable) |
| Allowed Values | 8 characters (diagnosis code qualifier)
1 character (Y/N) |
| Notes |
|
Field does not exist in Claim.MD form
| Field Name | Reserved for Assignment by the NUBC |
|---|
|
| Description | N/A |
| Paper Claim Block | 68 |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | N/A |
| Allowed Values | N/A |
| Notes |
|
| Field Name | Admitting Diagnosis Code |
|---|
|
| Description | "Admitting Diagnosis Code" is a medical code used to identify the primary reason for a patient's admission to a healthcare facility, aiding in accurate classification, documentation, and claims processing for the patient's condition. |
| Paper Claim Block | 69 |
| Required / Situational | Situational |
| XML / JSON Field | admit_diag -HI01-1 (Value ABJ – ICD10), HI01-2 (Code) |
| X12 Loop / Segment | 2300 |
| Allowed Values | N/A |
| Notes |
|
Field does not exist in Claim.MD form
| Field Name | Patient Reason Code |
|---|
|
| Description | "Patient Reason Code" is a code used to indicate the patient's specific reason for seeking medical care or undergoing a healthcare service, aiding in accurate documentation and claims processing. It provides additional context about the patient's condition or situation that led to the need for medical attention. |
| Paper Claim Block | 70 |
| Required / Situational | Situational |
| XML / JSON Field | diag_1, diag_2, diag_3, diag_4, diag_5, diag_6, diag_7, diag_8, diag_9, diag_10, diag_11, diag_12
diag_1_poa, diag_2_poa, diag_3_poa, diag_4_poa, diag_5_poa, diag_6_poa, diag_7_poa, diag_8_poa, diag_9_poa, diag_10_poa, diag_11_poa, diag_12_poa |
| X12 Loop / Segment | Loop 2300 - HI01-1 (Value APR – ICD10) HI01-2 (Code) |
| Allowed Values | 8 characters (diagnosis code qualifier)
1 character (Y/N) |
| Notes |
|
| Field Name | Diagnosis Related Group Number |
|---|
|
| Description | "Diagnosis-Related Group (DRG) Number" is a code used to categorize and group together patients with similar clinical conditions who require similar levels of hospital resources. DRG codes are used for billing and reimbursement purposes, helping healthcare facilities receive appropriate payment based on the complexity and severity of cases they treat. |
| Paper Claim Block | 71 |
| Required / Situational | Situational |
| XML / JSON Field | drg |
| X12 Loop / Segment | HI01-1 (Value DR – Diagnosis Related Group, HI01-2 (MS-DRG) |
| Allowed Values | 3 characters |
| Notes |
|
| Field Name | External Injury Code 1-3, External Injury Present on Admission 1- |
|---|
|
| Description | "Diagnosis Code Qualifier" refers to a code that indicates the type of diagnosis code being reported, such as "ICD" for International Classification of Diseases, aiding in accurate identification and categorization of medical conditions for billing and claims processing in healthcare.
"Principal Diagnosis Code and Present on Admission (POA) Indicator" involves reporting the primary diagnosis code for the patient's condition along with an indicator that specifies whether the condition was present upon admission to the healthcare facility, crucial for accurate billing and claims processing, and assessment of hospital-acquired conditions. |
| Paper Claim Block | 72a-c |
| Required / Situational | Situational |
| XML / JSON Field | 2300 - HI01-1 (Value DR – Diagnosis Related, HI01-2 (MS-DRG) |
| X12 Loop / Segment | e_code, e_code_2, e_code_3
e_code_1_poa, e_code_2_poa, e_code_3_poa |
| Allowed Values | 8 characters (diagnosis code qualifier)
1 character (Y/N) |
| Notes |
|
Field does not exist in Claim.MD form
| Field Name | Reserved for Assignment by the NUBC |
|---|
|
| Description | N/A |
| Paper Claim Block | 73 |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | N/A |
| Allowed Values | N/A |
| Notes |
|
Facility Claim- Block 74-75
Principal Procedure
| Field Name | Principal Procedure Code and Date (The ICD-9-CM for Principal Procedure) |
|---|
|
| Description | Refers to reporting the primary medical procedure or surgical intervention code along with the date it was performed during a patient's hospital stay, aiding in accurate billing, claims processing, and documentation of the significant medical action related to the primary diagnosis. |
| Paper Claim Block | 74 |
| Required / Situational | Situational |
| XML / JSON Field | proc_clmcode_1, proc_date_1_date |
| X12 Loop / Segment | Loop 2300 - HI01-1 (Value BBR– ICD10), HI01-2 (Code), HI01-3 (Value D8 – Format: , CCYYMMDD), HI01-4 (Date Performed) |
| Allowed Values | Text 8 (code)
Date yyyymmdd (date) |
| Notes |
|
| Field Name | Other Procedure and Date a-e |
|---|
|
| Description | involves reporting additional medical procedure or surgical intervention codes along with their corresponding dates of performance during a patient's hospital stay, ensuring accurate billing, claims processing, and proper documentation of supplementary medical actions. |
| Paper Claim Block | 74a-e |
| Required / Situational | Situational |
| XML / JSON Field | proc_clmcode_2, proc_clmcode_3, proc_clmcode_4, proc_clmcode_5, proc_clmcode_6 |
| X12 Loop / Segment | 2300 - HI01-1 (Value BBR, HI01-2 (Code), HI01-3 (Value D8 – Format: CCYYMMDD), HI01-4 (Date Performed) |
| Allowed Values | Text 8 (code)
Date yyyymmdd (date) |
| Notes |
|
Field does not exist in Claim.MD form
| Field Name | Reserved for Assignment by the NUBC |
|---|
|
| Description | N/A |
| Paper Claim Block | 75 |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | N/A |
| Allowed Values | N/A |
| Notes |
|
Facility Claim- Block 76-79
Attending, Operating, Other Physician Information
| Field Name | Attending Provider Name (Last, First, Middle) |
|---|
|
| Description | Refers to the full name of the healthcare provider who is primarily responsible for overseeing and directing the patient's care during their hospital stay, aiding in accurate identification, communication, and claims processing. |
| Paper Claim Block | 76 |
| Required / Situational | Situational |
| XML / JSON Field | prov_name_l, prov_name_f, prov_name_m |
| X12 Loop / Segment | 2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code) |
| Allowed Values | 35 characters, 25 characters, 25 characters |
| Notes |
|
| Field Name | Attending Provider NPI and Provider ID |
|---|
|
| Description | These are both unique identifiers used to distinguish healthcare providers. The NPI is a standardized numeric code assigned to individual healthcare providers or organizations, while the Provider ID is a specific identifier assigned by a healthcare facility or insurer to a provider within their network. These identifiers play a crucial role in accurate communication, billing, and claims processing in the healthcare industry. |
| Paper Claim Block | 76 |
| Required / Situational | Situational |
| XML / JSON Field | prov_npi, prov_id |
| X12 Loop / Segment | 2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code) |
| Allowed Values | Numeric 10, 32 characters |
| Notes |
|
| Field Name | Attending Provider Taxonomy |
|---|
|
| Description | This refers to the specific Healthcare Provider Taxonomy Code that classifies the professional specialty or area of expertise of the attending healthcare provider overseeing a patient's care during their hospital stay, aiding in accurate categorization, communication, billing, and claims processing. |
| Paper Claim Block | 76 |
| Required / Situational | Situational |
| XML / JSON Field | prov_taxonomy |
| X12 Loop / Segment | 2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code) |
| Allowed Values | 10 characters |
| Notes |
|
| Field Name | Operating Provider Name (Last, First, Middle) |
|---|
|
| Description | This is the full name of the healthcare professional who performs the primary procedure or surgery on a patient during a hospital stay, aiding in accurate identification, communication, billing, claims processing, and documentation of the responsible provider for the performed medical intervention. |
| Paper Claim Block | 77 |
| Required / Situational | Situational |
| XML / JSON Field | 2310A -NM101 (Value 72 – Operating Provider)NM102 (Value 1 – Person), NM103 (Last NameNM104 (First Name), NM105 (Middle Name), NM108 (ValueXX), NM109 (NPI)PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code) |
| X12 Loop / Segment | prov2_name_l, prov2_name_f, prov2_name_m |
| Allowed Values | 32 characters (last), 32 characters (first), 1 character (middle) |
| Notes |
|
| Field Name | Operating Provider NPI and Provider ID |
|---|
|
| Description | This is the unique National Provider Identifier for the healthcare professional performing a primary procedure or surgery, and "Operating Provider ID" is the facility-assigned identifier, both vital for precise communication, billing, and claims processing. |
| Paper Claim Block | 77 |
| Required / Situational | Situational |
| XML / JSON Field | prov2_npi, prov2_id |
| X12 Loop / Segment | 2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code) |
| Allowed Values | Numeric 10, 32 characters |
| Notes |
|
| Field Name | Operating Provider Taxonomy |
|---|
|
| Description | This refers to the specific Healthcare Provider Taxonomy Code that classifies the professional specialty or area of expertise of the healthcare provider performing the primary procedure or surgery during a patient's hospital stay, aiding in accurate categorization, communication, billing, and claims processing. |
| Paper Claim Block | 77 |
| Required / Situational | Situational |
| XML / JSON Field | prov2_taxonomy |
| X12 Loop / Segment | 2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code) |
| Allowed Values | 10 characters |
| Notes |
|
| Field Name | Other Provider Name (Last, First, Middle) |
|---|
|
| Description | Refers to the full name of a healthcare provider, other than the attending or operating provider, who played a role in the patient's care during their hospital stay, aiding in accurate identification, communication, billing, claims processing, and documentation of all involved providers. |
| Paper Claim Block | 78 (and 79) |
| Required / Situational | Situational |
| XML / JSON Field | 2310C, 2310D, 2310F - NM101 (Value DN – Referring Provider, ZZ – Other Operating Provider, or 82 – Rendering Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC - Taxonomy), PRV03 (Taxonomy Code) |
| X12 Loop / Segment | prov3_name_l, prov3_name_f, prov3_name_m |
| Allowed Values | 32 characters (last), 32 characters (first), 1 character (middle) |
| Notes |
|
| Field Name | Other Provider NPI and Provider ID |
|---|
|
| Description | This is the National Provider Identifier for a healthcare provider, not the attending or operating provider, involved in the patient's care, and "Other Provider ID" is the facility-assigned identifier for the same provider, both essential for precise communication, billing, and claims processing. |
| Paper Claim Block | 78 (and 79) |
| Required / Situational | Situational |
| XML / JSON Field | prov3_npi, prov3_id |
| X12 Loop / Segment | 2310C, 2310D, 2310F - NM101 (Value DN – Referring Provider, ZZ – Other Operating Provider, or 82 – Rendering Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC - Taxonomy), PRV03 (Taxonomy Code) |
| Allowed Values | Numeric 10, 32 characters |
| Notes |
|
| Field Name | Other Provider Taxonomy |
|---|
|
| Description | This refers to the specific Healthcare Provider Taxonomy Code that classifies the professional specialty or area of expertise of the healthcare provider performing the primary procedure or surgery during a patient's hospital stay, aiding in accurate categorization, communication, billing, and claims processing. |
| Paper Claim Block | 78 (and 79) |
| Required / Situational | Situational |
| XML / JSON Field | prov3_taxonomy |
| X12 Loop / Segment | 2310A - NM101 (Value 71 – Attending Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC – Taxonomy), PRV03 (Taxonomy Code) |
| Allowed Values | 10 characters |
| Notes |
|
| Field Name | Referring Provider Name (Last, First, Middle) |
|---|
|
| Description | Refers to the full name of the healthcare provider who recommended or referred the patient for a hospital stay or specific medical services, aiding in accurate identification, communication, billing, claims processing, and documentation of the provider's role in the patient's care. |
| Paper Claim Block | 78 (and 79) |
| Required / Situational | Situational |
| XML / JSON Field | 2310C, 2310D, 2310F - NM101 (Value DN – Referring Provider, ZZ – Other Operating Provider, or 82 – Rendering Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC - Taxonomy), PRV03 (Taxonomy Code) |
| X12 Loop / Segment | ref_name_l, ref_name_f, ref_name_m |
| Allowed Values | 35 characters (last), 25 characters (first), 25 character (middle) |
| Notes |
|
| Field Name | Referring Provider NPI and Provider ID |
|---|
|
| Description | This is the National Provider Identifier for the healthcare provider who recommended or referred the patient, and "Referring Provider ID" is the facility-assigned identifier for the same provider, both essential for precise communication, billing, and claims processing. |
| Paper Claim Block | 78 (and 79) |
| Required / Situational | Situational |
| XML / JSON Field | ref_npi, ref_id |
| X12 Loop / Segment | 2310C, 2310D, 2310F - NM101 (Value DN – Referring Provider, ZZ – Other Operating Provider, or 82 – Rendering Provider), NM102 (Value 1 – Person), NM103 (Last Name), NM104 (First Name), NM105 (Middle Name), NM108 (Value XX), NM109 (NPI), PRV01 (Value AT – Attending), PRV02 (Value PXC - Taxonomy), PRV03 (Taxonomy Code) |
| Allowed Values | Numeric 10, 32 characters |
| Notes |
|
| Field Name | Rendering Provider Name (Last, First, Middle) |
|---|
|
| Description | Refers to the full name of the healthcare provider who performed the medical services or procedures for the patient, aiding in accurate identification, communication, billing, claims processing, and documentation of the provider responsible for the provided healthcare services. |
| Paper Claim Block | 78 (and 79) |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | N/A |
| Allowed Values | 35 characters (last), 25 characters (first), 25 character (middle) |
| Notes |
|
| Field Name | Rendering Provider NPI and Provider ID |
|---|
|
| Description | This is the National Provider Identifier for the healthcare provider who performed the medical services or procedures, and "Rendering Provider ID" is the facility-assigned identifier for the same provider, both crucial for precise communication, billing, and claims processing. |
| Paper Claim Block | 78 (and 79) |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | N/A |
| Allowed Values | Numeric 10, 32 characters |
| Notes |
|
Facility Claim- Block 80-81
Remarks
| Field Name | Remarks |
|---|
|
| Description | This field provides space for additional notes or comments that healthcare providers may wish to include regarding the patient's condition, treatment, or any other relevant information. This section allows for supplementary details that could aid in accurate billing, claims processing, or provide context for the patient's care. |
| Paper Claim Block | 80 |
| Required / Situational | Situational |
| XML / JSON Field | N/A |
| X12 Loop / Segment | Loop 2300 - NTE01 (Value ADD), NTE02 (Notes) |
| Allowed Values | 80 characters |
| Notes | Note that the field can be enlarged for longer comments by clicking and dragging the right corner |
Field not displayed on Claim.MD form
| Field Name | 81a-d Code-Code |
|---|
|
| Description | Refers to the codes used to specify the type of healthcare facility and specific accommodation or room category where the patient received treatment during their hospital stay. These codes help categorize and communicate details about the patient's accommodations for accurate billing, claims processing, and documentation. |
