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.
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
Reserved for Assignment by the NUBC
Field name not displayed
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)
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.
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.
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.
"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.
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.
"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.
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)
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.
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.
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.
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.
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.
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
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)
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.
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.
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.
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
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.
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.
"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.
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)
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
