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Professional Claim Form Overview

20 Mar 2024
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Professional Claim Form Overview

Updated on 20 Mar 2024
38 Minutes to read

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The electronic form used in modern healthcare billing is based on the HCFA 1500 paper form, also known as the CMS-1500 form. The Claim.MD online version of this form retains the familiarity of the standard paper form but allows for additional electronic elements supported in the 837P electronic claim standard. This document gives a description of each field on the claim form and a crosswalk to their associated electronic elements.

The paper version of the claim form (HCFA 1500) can be visually compared to identify the differences. For instance, on the paper claim form, the patient/authorized person's signature is placed in Block 12, while the insured/authorized signature is in Block 13. However, these blocks are not present in the electronic Claim.MD version.

This crosswalk serves as a reference, and much of the data used in the X12 ANSI format is derived from the content presented on the website.

Claim.MD Professional Claim Form (as seen in View/Edit Claim page)

Professional Claim- Block 1
Payer Information

Field Name	Payer Name

Description	The name of the insurance payer or health plan.
Paper Claim Block	1
Required / Situational	Required
XML / JSON Field	payer_name
X12 Loop / Segment	Loop 2010BB / NM103
Allowed Values	64 characters
Notes	Information obtained from insurance card or directly from insurance provider. See Claim.MD payer list for a searchable list of payers already in the Claim.MD database. XLSX: https://www.claim.md/payer_list.xlsx

Field Name	Payer ID

Description	The unique identifier for the primary payer.
Paper Claim Block	1
Required / Situational	Required
XML / JSON Field	payerid
X12 Loop / Segment	Loop 2000B / SBR09
Allowed Values	32 characters
Notes	Information obtained from insurance card or directly from insurance provider. See Claim.MD payer list for a searchable list of payers already in the Claim.MD database. XLSX: https://www.claim.md/payer_list.xlsx

Field Name	Payer Address

Description	The address of the insurance payer or health plan.
Paper Claim Block	1
Required / Situational	Situational
XML / JSON Field	payer_addr_1
X12 Loop / Segment	Loop 2010BB / N301
Allowed Values	55 characters
Notes	Information obtained from insurance card or directly from insurance provider. Payer address is not required on electronic claims.

Field Name	Payer Address 2

Description	Additional address line of the insurance payer or health plan.
Paper Claim Block	1
Required / Situational	Situational
XML / JSON Field	payer_addr_2
X12 Loop / Segment	Loop 2010BB / N302
Allowed Values	55 characters
Notes	Information obtained from insurance card or directly from insurance provider. See Claim.MD payer list for a searchable list of payers already in the Claim.MD database. Create a support ticket if a payer is not on the list.

Field Name	Payer City

Description	The name of the insurance payer or health plan.
Paper Claim Block	1
Required / Situational	Situational
XML / JSON Field	payer_city
X12 Loop / Segment	Loop 2010BB / N401
Allowed Values	30 characters
Notes	Information obtained from insurance card or directly from insurance provider. See Claim.MD payer list for a searchable list of payers already in the Claim.MD database. Create a support ticket if a payer is not on the list.

Field Name	Payer State

Description	The state where the insurance payer or health plan is located.
Paper Claim Block	1
Required / Situational	Situational
XML / JSON Field	payer_state
X12 Loop / Segment	Loop 2010BB / N402
Allowed Values	2 characters
Notes	Information obtained from insurance card or directly from insurance provider. See Claim.MD payer list for a searchable list of payers already in the Claim.MD database. Create a support ticket if a payer is not on the list.

Field Name	Payer Zip Code

Description	The ZIP code of the insurance payer or health plan.
Paper Claim Block	1
Required / Situational	Situational
XML / JSON Field	payer_zip
X12 Loop / Segment	Loop 2010BB / N403
Allowed Values	15 characters
Notes

Field Name	Insured I.D. Number

Description	The identification number of the insured individual.
Paper Claim Block	1a
Required / Situational	Required
XML / JSON Field	ins_number
X12 Loop / Segment	Loop 2010BA / NM109
Allowed Values	32 characters
Notes	Provide the insured's ID number exactly as it appears on their ID card for the payer to whom the claim is being submitted. In case the patient has a specific Member Identification Number assigned by the payer, please enter that number in this field.

Professional Claim- Block 2-4
Patient Information

Field Name	Patient Name

Description	The full last name, first name, and middle initial of the patient receiving the medical services.
Paper Claim Block	2
Required / Situational	Required (except for middle initial)
XML / JSON Field:	pat_name_l, pat_name_f, pat_name_m
X12 Loop / Segment	Loop 2010BA / NM103 / NM104 / NM105
Allowed Values	35 characters (last name) / 25 characters (first name) / 25 characters (middle initial)
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Patient Date of Birth

Fieldname	Patient Date of Birth
Description	The date of birth of the patient.
Paper Claim Block	3
Required / Situational	Required
XML / JSON Field	pat_dob
X12 Loop / Segment	Loop 2010BA / DMG02
Allowed Values	10 characters, Date format (MM-DD-YYYY)
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Patient Sex

Description	The sex of the patient.
Paper Claim Block	2
Required / Situational	Required
XML / JSON Field	patient_sex
X12 Loop / Segment	Loop 2010BA / DMG03
Allowed Values	1 character - M (Male), F (Female), U (Unknown)
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Insured's Name

Description	The full last name, full first name, middle initial of insured individual. The insured individual is the person who holds the policy.
Paper Claim Block	4
Required / Situational	Situational
XML / JSON Field	ins_name_l, ins_name_f, ins_name_m
X12 Loop / Segment	Loop 2010BA / NM103, NM104, NM105, NM107
Allowed Values	35 characters (last name) / 25 characters (first name) / 25 characters (middle initial)
Note	Information usually obtained from insurance card.

Professional Claim- Block 5-8
Patient Information / Insured's Information

Field Name	Patient Address

Description	The first line of the patient's address.
Paper Claim Block	5
Required / Situational	Required
XML / JSON Field	ins_addr_1
X12 Loop / Segment	Loop 2010CA / N301
Allowed Values	55 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Patient Address 2

Description	The second line of the patient's address (if applicable).
Paper Claim Block	5
Required / Situational	Situational
XML / JSON Field	ins_addr_2
X12 Loop / Segment	Loop 2010CA / N302
Allowed Values	55 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Patient City

Description	The city where the patient resides.
Paper Claim Block	5
Required / Situational	Required
XML / JSON Field	pat_city
X12 Loop / Segment	Loop 2010CA / N401
Allowed Values	30 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Patient State

Description	The state where the patient resides.
Paper Claim Block	5
Required / Situational	Required
XML / JSON Field	pat_state
X12 Loop / Segment	Loop 2010CA / N402
Allowed Values	2 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Patient Zip Code

Description	The ZIP code of the patient's address.
Paper Claim Block	5
Required / Situational	Required
XML / JSON Field	pat_zip
X12 Loop / Segment	Loop 2010CA / N403
Allowed Values	15 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Patient Country Code


Description	The country code of the patient's address (if applicable).
Paper Claim Block	5
Required / Situational	Situational
XML / JSON Field	pat_country
X12 Loop / Segment	Loop 2010CA - N4
Allowed Values	2 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Patient Phone Number

Description	The phone number of the patient.
Paper Claim Block	5
Required / Situational: Situational	Situational
XML / JSON Field:	pat_phone
X12 Loop / Segment	Loop 2010CA - PER
Allowed Values	10 characters
Note	*Not on Claim.MD form. Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Patient Relationship

Description	The relationship of the patient to the insured individual.
Paper Claim Block	6
Required / Situational	Required
XML / JSON Field	pat_rel
X12 Loop / Segment	Loop 2000B / 2000C - SBR02 / PAT01
Allowed Values	2 characters - codes representing patient relationships to insured (e.g., 18 for Self, 01 for Spouse, 19 for Child)
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Insured's Address

Description	The first line of the insured individual's address.
Paper Claim Block	7
Required / Situational	Situational
XML / JSON Field	<insured_address_1>
X12 Loop / SegmentX12 Loop / Segment	2010BA - N301
Allowed Values	55 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Insured's Address 2

Description	The second line of the insured individual's address (if applicable).
Paper Claim Block	7
Required / Situational	Situational
XML / JSON Field	ins_addr_2
X12 Loop / Segment	Loop 2010BA - N302
Allowed Values	55 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Insured's City

Description	The city where the insured individual resides.
Paper Claim Block	7
Required / Situational	Situational
XML / JSON Field	ins_city
X12 Loop / Segment	Loop 2010BA - N401
Allowed Values	30 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Insured's State

Description	The state where the insured individual resides.
Paper Claim Block	7
Required / Situational	Situational
XML / JSON Field	ins_state
X12 Loop / Segment	2010BA - N42010BA - N402
Allowed Values	2 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Insured Zip

Description	The ZIP code of the insured individual's address.
Paper Claim Block	7
Required / Situational	Situational
XML / JSON Field	ins_zip
X12 Loop / Segment	2010BA - N403
Allowed Values	15 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Insured Country Code

Description	The country code of the insured individual's address (if applicable).
Paper Claim Block	7
Required / Situational	Situational
XML / JSON Field	ins_country
X12 Loop / Segment	Loop 2010BA - N4
Allowed Values	2 characters
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field not visible on claim form

Field Name	Insured Phone Number
Description	The phone number of the insured individual.
Paper Claim Block	7
Required / Situational	Situational
XML / JSON Field	ins_phone
X12 Loop / Segment	Loop 2010BA - PER
Allowed Values	10 characters
Note	Not on electronic form. Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Field Name	Marital and Work Status

Description	This field indicates the marital status and work status of the patient, providing information about their marital relationship and current employment status.
Paper Claim Block	8
Required / Situational	Situational
XML / JSON Field	pat_marital
X12 Loop / Segment	Patient Status does not exist in the 837P
Allowed Values	1 character Y/N - Marital (Single, Married, Other); Employment (Employed, Full-time student, Part-time student)
Note	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc

Professional Claim- Block 9
Secondary Insured's Information / Medicare Type Code

Fieldname	Secondary Insured Last Name

Description	The last name or surname of the insured individual for other insurance.
Paper Claim Block	9
Required / Situational	Situational
XML / JSON Field	other_ins_name_l
X12 Loop / Segment	Loop 2330A- NM103 (Name)
Allowed Values	35 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Insured First Name

Description	The last name or surname of the insured individual for other insurance.
Paper Claim Block	9
Required / Situational	Situational
XML / JSON Field	other_ins_name_f
X12 Loop / Segment	Loop 2330A- NM104 (Name)
Allowed Values	35 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Insured's Middle Name

Description	The middle name or initial of the insured individual for other insurance.
Paper Claim Block	9
Required / Situational	Situational
XML / JSON Field:	other_ins_name_m
X12 Loop / Segment	Loop 2330A - NM105
Allowed Values	25 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Insured's Policy Number

Description	The policy number associated with the other insurance coverage.
Paper Claim Block	9a
Required / Situational	Situational
XML / JSON Field	other_ins_number
X12 Loop / Segment	Loop 2320 - SBR03
Allowed Values	32 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Insured's Date of Birth

Description	The date of birth of the insured individual for other insurance.
Paper Claim Block	9b (this field is typically not part of the standard CMS-1500 (02/12) paper claim form.)
Required / Situational	Situational
XML / JSON Field	other_ins_dob
X12 Loop / Segment	Loop 2320B- DMG02
Allowed Values	Date format (yyyymmdd)
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Insured's Sex

Description	The gender or sex of the insured individual for other insurance.
Paper Claim Block	9b (this field is typically not part of the standard CMS-1500 (02/12) paper claim form.)
Required / Situational	Situational
XML / JSON Field	other_ins_sex
X12 Loop / Segment	Loop 2320B - DMG03
Allowed Values	2 characters - M (Male), F (Female), U (Unknown), or other valid gender codes.
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Payment Date

Description	The "Primary Payment Date" refers to the date when the primary insurance payer made the payment for the healthcare services rendered.
Paper Claim Block	9c (this field is not part of the standard CMS-1500 (02/12) paper claim form.)
Required / Situational	N/A (Not applicable as this field is not included in the standard CMS-1500 (02/12) paper claim form.)
XML / JSON Field	other_ins_payment_date
X12 Loop / Segment	Loop 2330B / Segment DTP / Qualifier 573
Allowed Values	Date yyyymmdd
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Payer's Name

Description	The name of the other insurance payer or health plan that is responsible for processing the claim as a secondary or tertiary payer.
Paper Claim Block	9d
Required / Situational	Situational
XML / JSON Field	other_payer_name
X12 Loop / Segment	Loop 2320 - SBR04 OI
Allowed Values	32 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Insurance Payer ID

Description	The identification number of the insurance payer for other insurance.
Paper Claim Block	9d
Required / Situational	Situational
XML / JSON Field	other_payerid
X12 Loop / Segment	Loop 2320 - REF01
Allowed Values	8 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Payer's Claim ID

Description	The unique identification number assigned to the claim by the other insurance payer.
Paper Claim Block	9d
Required / Situational	Situational
XML / JSON Field	other_payerid
X12 Loop / Segment	Loop 2320 - REF02
Allowed Values	Allowed Values
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Payer Address 1

Description	The first line of the address of the other insurance payer.
Paper Claim Block	9d
Required / Situational	Situational
XML / JSON Field	other_payer_addr_1
X12 Loop / Segment	Loop 2320 / N301
Allowed Values	55 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Payer Address 2

Description	The second line of the address of the other insurance payer.
Paper Claim Block	9d
Required / Situational	Situational
XML / JSON Field	other_payer_addr_2
X12 Loop / Segment	Loop 2320 / N302
Allowed Values	55 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Payer City

Description	The city where the other insurance payer is located.
Paper Claim Block	9d
Required / Situational	Situational
XML / JSON Field	other_payer_city
X12 Loop / Segment	Loop 2320 / N401
Allowed Values	2 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Payer State

Description	The state where the other insurance payer is located.
Paper Claim Block	9d
Required / Situational	Situational
XML / JSON Field	other_payer_state
X12 Loop / Segment	Loop 2320 / N402
Allowed Values	Two-letter state abbreviation.
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Payer Zip

Description	The ZIP code of the other insurance payer's location.
Paper Claim Block	9d
Required / Situational	Situational
XML / JSON Field	other_payer_zip
X12 Loop / Segment	Loop 2320 / N403
Allowed Values	15 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Medicare Type Code

Description	The Medicare Type Code indicates the type of Medicare program or plan under which the patient is covered.
Paper Claim Block	9d
Required / Situational	Situational
XML / JSON Field	other_ins_medicare_code
X12 Loop / Segment	Loop 2300 / EB04
Allowed Values	2 characters
Note	The Medicare Type Code is specific to Medicare claims and may not be applicable to other insurance payers. It is used to indicate the type of Medicare coverage for the patient's claim

Fieldname	Secondary Policy Relationship

Description	The relationship of the insured to the policyholder or primary beneficiary of the other insurance policy.
Paper Claim Block	9e
Required / Situational	Situational
XML / JSON Field	other_pat_rel
X12 Loop / Segment	Loop 2320B / SBR02
Allowed Values	2 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Policy Group Name

Description	The name of the group or employer providing the other insurance coverage, if applicable.
Paper Claim Block	9f
Required / Situational	Situational
XML / JSON Field	other_ins_group
X12 Loop / Segment	Loop 2320B - REF02
Allowed Values	30 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Secondary Policy Number

Description	The identification number or code of the other insurance policy covering the patient's healthcare services.
Paper Claim Block	9g
Required / Situational	Situational
XML / JSON Field	other_ins_number
X12 Loop / Segment	Loop 2320B - REF01
Allowed Values	30 characters
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Professional Claim- Block 10
Accident / Auto Related

Fieldname	Accident Related to Employment

Description	Indicates whether the accident is related to employment.
Paper Claim Block	10a
Required / Situational	Situational
XML / JSON Field	employment_related
X12 Loop / Segment	Loop 2300 - CLM11 PWK
Allowed Values	1 character - Y (Yes), N (No)
Notes

Fieldname	Accident Related to Auto

Description	Indicates whether the accident is related to an automobile accident.
Paper Claim Block	10b
Required / Situational	Situational
XML / JSON Field	auto_accident
X12 Loop / Segment	Loop 2300 - CLM11 PWK
Allowed Values	1 character - Y (Yes), N (No)
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Auto Accident State

Description	The state where the auto accident occurred.
Paper Claim Block	10b
Required / Situational	Situational
XML / JSON Field	auto_accident_state
X12 Loop / Segment	Loop 2300 - CLM11 PWK (Claim Supplemental Information)
Allowed Values	Two-letter state abbreviation
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Other Accident Related

Description	Indicates whether the accident is related to another type of accident.
Paper Claim Block	10c
Required / Situational	Situational
XML / JSON Field	other_accident
X12 Loop / Segment	Loop 2300 - CLM11 PWK
Allowed Values	1 character - Y (Yes), N (No)
Notes	Information obtained from intake forms and/or PMS / EMR systems, insurance information, etc.

Fieldname	Condition Code (1, 2, 3)

Description	Claim codes in field refer to the codes used to indicate specific conditions or reasons for the claim submission. These codes provide additional information related to the claim and may help in processing and adjudicating the claim accurately.
Paper Claim Block	10d
Required / Situational	Situational
XML / JSON Field	cond_code_1, cond_code_2, cond_code_3
X12 Loop / Segment	Loop 2300 - HI CLM
Allowed Values	2 characters Common examples include: "A0" - Medical Emergency "B3" - Change in Diagnosis or Misdiagnosis "B7" - Performed Prior to Authorization "P4" - Item Provided as a Preoperative Service Only "PR" - Patient Responsibility "PI" - Primary Insurance "OA" - Other Accident "NU" - New Equipment "GW" - Service Not Related to the Hospice Patient's Terminal Condition "ZA" - Medicare Blood Deductible "ZZ" - Mutually Defined
Notes	The specific claim codes used may vary depending on the payer's guidelines and requirements. Providers should use appropriate and accurate claim codes to ensure proper processing and payment of the claim.

Professional Claim- Block 11
Insured's Information

Fieldname	Insured's Policy Group

Description	The group number associated with the insured individual's insurance plan.
Paper Claim Block	11
Required / Situational	Situational
XML / JSON Field	ins_group
X12 Loop / Segment	Loop 2000B - SBR03 REF
Allowed Values	30 characters
Notes	Insurance Information

Fieldname	Insured Date of Birth

Description	The date of birth of the insured individual.
Paper Claim Block	11a
Required / Situational	Situational
XML / JSON Field	ins_dob
X12 Loop / Segment	Loop 2010BA - DMG02
Allowed Values	Date format yyyymmdd
Notes	Insurance Information

Fieldname	Insured Gender

Description	The gender of the insured individual.
Paper Claim Block	11a
Required / Situational	Situational
XML / JSON Field	ins_sex
X12 Loop / Segment	Loop 2010BA - DMG03
Allowed Values	1 character - M (Male), F (Female), U (Unknown)
Notes	Insurance Information

Fieldname	Insured Employer Name/School Name/ Other Claim ID

Description	The name of the insured individual's employer.
Paper Claim Block	11b
Required / Situational	Situational
XML / JSON Field	ins_employer
X12 Loop / Segment	Loop 2010BA - REF01, REF02
Allowed Values	32 characters
Notes	Insurance Information

Fieldname	Insured Plan Name

Description	The name of the insured individual's insurance plan.
Paper Claim Block	11c
Required / Situational	Situational
XML / JSON Field	ins_plan
X12 Loop / Segment	Loop 2000B - SBR04
Allowed Values	30 characters
Notes	Insurance Information

Fieldname	Supervisor Name / ID / NPI

Description	The name of the supervisor or overseeing healthcare professional who provided or supervised the healthcare services.
Paper Claim Block	N/A (Not applicable as this field is not part of the standard CMS-1500 (02/12) paper claim form.)
Required / Situational	Situational
XML / JSON Field	chg_supv_prov_name_l, chg_supv_prov_name_f, chg_supv_prov_name_m, chg_supv_prov_npi, chg_supv_prov_id
X12 Loop / Segment	N/A (Not applicable as this field is not part of the standard X12 EDI format for electronic claim submissions based on the CMS-1500 form.)
Allowed Values	55 characters
Notes	Insurance Information

Professional Claim- Block 14-19
Date of Condition, Referring Physician, Hospitalization dates, Claim Narrative,

More Information

Note that selecting an option from the ADD DATE field, will add a new date field under DATE OF CONDITION.

Fieldname	Date of Condition / Date of Current illness, injury, pregnancy (LMP)

Description	The date when the current illness, injury, or pregnancy began.
Paper Claim Block	14
Required / Situational	Situational
XML / JSON Field	cond_date
X12 Loop / Segment	Loop 2300 - DTP01 / DTP03
Allowed Values	Date yyyymmdd
Notes	Usually from PMS / EMR, medical notes, etc.

Fieldname	Date of Onset

Description	The date when the patient's symptoms or condition first started or when an injury occurred.
Paper Claim Block	15
Required / Situational	Situational
XML / JSON Field	onset_date
X12 Loop / Segment	Loop 2300 - DTP01, DTP03
Allowed Values	Date yyyymmdd
Notes	Usually from PMS / EMR, medical notes, etc.

Fieldname	Date Last Seen

Description	The date when the patient was last seen for treatment or evaluation.
Paper Claim Block:	15
Required / Situational	Situational
XML / JSON Field	lastseen_date
X12 Loop / Segment	Loop 2300 - DTP01, DT03
Allowed Values	Date format yyyymmdd
Notes	This field displays once Last Date Seen is selected in the Add Date dropdown. Usually from PMS / EMR, medical notes, etc.

Fieldname	Unable to Work From Date

Description	The date when the patient became unable to work due to the reported condition or injury.
Paper Claim Block	16
Required / Situational	Situational
XML / JSON Field	nowork_from_date
X12 Loop / Segment	Loop 2300 - DTP03
Allowed Values	Date yyyymmdd
Notes	Usually from PMS / EMR, medical notes, etc.

Fieldname	Unable to Work To Date

Description	The phrase "Unable to Work To Date" indicates that the individual has been unable to work up to the current date, implying a continuous period of being unable to work until the present moment.
Paper Claim Block	16
Required / Situational	Situational
XML / JSON Field	nowork_from_date
X12 Loop / Segment	Loop 2300 - DTP03
Allowed Values	Date yyyymmdd
Notes	Usually from PMS / EMR, medical notes, etc.

Fieldname	Referring Provider Last Name

Description	The last name or surname of the referring provider.
Paper Claim Block	17
Required / Situational:	Situational
XML / JSON Field	ref_name_l
X12 Loop / Segment	Loop 2310A - NM101
Allowed Values	35 characters
Notes	Usually from PMS / EMR, medical notes, etc. Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Referring Provider First Name

Description	The first name or given name of the referring provider.
Paper Claim Block	17
Required / Situational	Situational
XML / JSON Field	ref_name_f
X12 Loop / Segment	Loop 2310A - NM103
Allowed Values	25 characters
Notes	Usually from PMS / EMR, medical notes, etc. Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Referring Provider Middle Name

Description	The middle name or initial of the referring provider.
Paper Claim Block	17
Required / Situational	Situational
XML / JSON Field:	ref_name_m
X12 Loop / Segment	Loop 2310A - NM104
Allowed Values	25 characters
Notes	Usually from PMS / EMR, medical notes, etc. Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Referring Provider NPI

Description	The National Provider Identifier (NPI) of the referring provider.
Paper Claim Block	Block: 17a
Required / Situational	Situational
XML / JSON Field	ref_npi
X12 Loop / Segment	Loop 2310A - NM109
Allowed Values	Numeric 10 characters
Notes	Usually from PMS / EMR, medical notes, etc. Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Referring Provider Atypical ID

Description	The atypical ID associated with the referring provider, if applicable.
Paper Claim Block	17b
Required / Situational	Situational
XML / JSON Field	ref_id
X12 Loop / Segment	Loop 2310A - REF01, REF02
Allowed Values:	32 characters
Notes	Usually from PMS / EMR, medical notes, etc. Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Hospital Admit Date / Dates Related to Current Services

Description	The date when the patient was admitted to the hospital.
Paper Claim Block	18
Required / Situational	Situational
XML / JSON Field:	hosp_from_date
X12 Loop / Segment:	Loop 2300 - DTP03
Allowed Values	Date yyyymmdd
Notes	Usually from PMS / EMR, medical notes, etc.

Fieldname	Hospital Discharge Date

Description	The date when the patient was discharged from the hospital.
Paper Claim Block	18
Required / Situational	Situational
XML / JSON Field	hosp_thru_date
X12 Loop / Segment	Loop 2300 - DTP03
Allowed Values	Date yyyymmdd
Notes	Usually from PMS / EMR, medical notes, etc.

Fieldname	Chiro Condition Manifest Date

Description	The date when the chiropractic condition was first manifested or diagnosed.
Paper Claim Block	19
Required / Situational	Situational
XML / JSON Field	chiro_manifest_date
X12 Loop / Segment	Loop 2310A - REF01, REF02
Allowed Values	Date yyyymmdd
Notes	Select "Acute Manifest Date" from the Add Date Field in block 14. Usually from PMS / EMR, medical notes, etc.

Professional Claim- Block 21
Diagnosis Codes

Fieldname	Diagnoses Code A

Description	The primary diagnosis code for the patient's condition or ailment.
Paper Claim Block	21
Required / Situational	Required
XML / JSON Field	diag_1
X12 Loop / Segment	Loop 2300 -HI01-2
Allowed Values	8 characters- ICD-10-CM codes (diagnosis codes).
Notes	Diag Codes Reference: https://www.cms.gov/medicare/icd-10/2023-icd-10-pcs Usually from PMS / EMR, medical notes, etc.

Professional Claim- Block 22-23
Resubmission Code / Prior Authorization # / Referral Number / CLIA Number

Fieldname	Medicaid Resubmission Code

Description	Code indicating the reason for resubmitting the claim (e.g., Original Claim, Void/Cancel of Prior Claim, etc.) plus a unique identifier assigned to a specific claim for tracking and internal record-keeping
Paper Claim Block	22
Required / Situational	Situational
XML / JSON Field	icn_dcn_1
X12 Loop / Segment	Loop 2300 - CLM05-3, 2300 - REF02
Allowed Values	32 characters
Notes	Resubmission refers to the process of providing the code and original reference number assigned by the destination payer or receiver, indicating a claim or encounter that has been submitted previously.

Fieldname	Prior Authorization Number

Description	The authorization number obtained from the payer for specific medical services or procedures.
Paper Claim Block	23
Required / Situational	Situational
XML / JSON Field	prior_auth
X12 Loop / Segment	Loop 2300 - REF02
Allowed Values	64 Characters
Notes	The "Prior Authorization Number" is the payer's assigned authorization number for the service(s).

Fieldname	Referral Number

Description	The number assigned to a medical referral from one healthcare provider to another.
Paper Claim Block	23
Required / Situational	Situational
XML / JSON Field	referral_number
X12 Loop / Segment	Loop 2300 - REF02
Allowed Values	32 characters
Notes

Fieldname	CLIA Number

Description	Clinical Laboratory Improvement Amendments (CLIA) number assigned to the laboratory performing the tests.
Paper Claim Block	23
Required / Situational	Situational
XML / JSON Field	clia_number
X12 Loop / Segment	Loop 2300 - REF02
Allowed Values	32 characters
Notes	CLIA Number reference: https://qcor.cms.gov/advanced_find_provider.jsp?which=4&backReport=active_CLIA.jsp

Professional Claim- Block 24
Service / Procedure / Charge and Units Information

Fieldname	Date of Service From

Description	The starting date of service for the billed procedure(s).
Paper Claim Block	24A
Required / Situational	Required
XML / JSON Field	from_date
X12 Loop / Segment	Loop 2400 - DTP03
Allowed Values	Date yyyymmdd
Notes	Usually from medical records, PMS/EMR, etc.

Fieldname	Date of Service To

Description	The ending date of service for the billed procedure(s) when multiple days were required.
Paper Claim Block	24A
Required / Situational	Situational
XML / JSON Field	thru_date
X12 Loop / Segment	Loop 2400 - DTP03
Allowed Values	Date yyyymmdd
Notes	Usually from medical records, PMS/EMR, etc.

Fieldname	Place of Service

Description	Code identifying where the services were rendered (e.g., office, home, hospital).
Paper Claim Block	Claim Block: 24B
Required / Situational	Situational
XML / JSON Field	place_of_service
X12 Loop / Segment	Loop 2300 CLM05-1 / 2400 - SV105
Allowed Values	2 characters
Notes	Usually from medical records, PMS/EMR, etc.

Fieldname	EMG

Description	Indicator for emergency services performed.
Paper Claim Block	24C
Required / Situational	Situational
XML / JSON Field	emergency_indicator
X12 Loop / Segment	Loop 2400 - SV109
Allowed Values	Yes/No in dropdown (1 character- "1" for emergency services, "0" for non-emergency services.)
Notes	Usually from medical records, PMS/EMR, etc.

Fieldname	Procedure Code

Description	Code(s) for the specific procedures, services, or supplies provided to the patient.
Paper Claim Block	24D
Required / Situational	Required
XML / JSON Field	proc_code
X12 Loop / Segment	Loop 2400 - SV101 (2-6)
Allowed Values	5 characters - codes identifying the procedures, services, or supplies.
Notes	CPT Codes references: https://www.ama-assn.org/topics/cpt-codes https://www.cms.gov/medicare/coding/hcpcsreleasecodesets/hcpcs-quarterly-update Usually from medical records, PMS/EMR, etc.

Fieldname	Modifier 1-4

Description	HCPCS modifiers are two-character codes appended to procedure codes to convey specific details about a healthcare service, such as "-GT" for telehealth services, enhancing accurate billing and claims processing.
Paper Claim Block	24D
Required / Situational	Required
XML / JSON Field	mod1, mod2, mod3, mod4
X12 Loop / Segment	Loop 2400 - SV101 (2-6)
Allowed Values	2 characters
Notes

Fieldname	Diagnosis Pointer

Description	Pointer(s) to the appropriate diagnosis code(s) in Block 21 related to the service or procedure performed.
Paper Claim Block	24E
Required / Situational	Required
XML / JSON Field	diag_ref
X12 Loop / Segment	Loop 2400 - SV107 (1-4)
Allowed Values	8 characters- Numeric pointers indicating the relevant diagnosis code(s) from Block 21.
Notes	Usually from medical records, PMS/EMR, etc.

Fieldname	Charge Amount

Description	The charges associated with each procedure or service provided.
Paper Claim Block	24F
Required / Situational	Required
XML / JSON Field	charge
X12 Loop / Segment	Loop 2400 - SV102
Allowed Values	9.2 characters - Monetary amount for each procedure or service.
Notes	Usually from medical records, PMS/EMR, etc.

Fieldname	Units Qualifier

Description	The number of days or units for each procedure or service provided.
Paper Claim Block	24G
Required / Situational	Required
XML / JSON Field	units
X12 Loop / Segment	Loop 2400 - SV104
Allowed Values	2 characters- Numeric value indicating the number of days or units.
Notes	Usually from medical records, PMS/EMR, etc.

More Information

Must click "Show Additional Charge Fields" to display the following:

NDC Code
NDC Dosage
NDC Measure
Fields 24H-L

Fieldname	Additional Narrative

Description	A brief text field used to provide supplementary details or context, especially when specific codes are unavailable or not fully descriptive.
Paper Claim Block	24
Required / Situational	Situational
XML / JSON Field	narrative
X12 Loop / Segment
Allowed Values	Text 80
Notes	Usually from medical records, PMS/EMR, etc.

Fieldname	NDC Code / NDC Dosage / NDC Measure

Description	NDC code: A unique identifier assigned to drugs and other healthcare products in the United States for tracking, billing, and drug classification purposes. NDC dosage: The specific strength or concentration of a medication represented by the NDC code, indicating the amount of the active ingredient per unit of administration (e.g., per tablet, per milliliter). NDC measure: The unit of measurement associated with the NDC code, indicating the quantity or volume of the medication or product being dispensed (e.g., number of tablets, milliliters of liquid).
Paper Claim Block	Not part of the paper claim HCFA 1500 (hidden under line 24 A-G)
Required / Situational	Situational
XML / JSON Field	ndc_code, ndc_dosage, ndc_measure
X12 Loop / Segment	N/A
Allowed Values	NDC Code (11 characters), NDC Dosage (7 characters), NDC Measure (2 characters)
Notes	NDC Code References: http://www.accessdata.fda.gov/ https://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=ndc

Fieldname	EPSDT / Family Plan

Description	Indicator for whether the service is related to an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) family plan.
Paper Claim Block	24H
Required / Situational	Situational
XML / JSON Field	epsdt_indicator
X12 Loop / Segment	Loop 2400 - SV111, SV112
Allowed Values	1 character - "Y" if the service is related to an EPSDT family plan, "N" if not applicable.
Notes	Usually from medical records, PMS/EMR, etc.

Fieldname	Ordering Provider Last Name, First Name, Middle Name:

Description	The personal name details of the healthcare professional responsible for placing an order, typically in the format of last name, first name, and middle name.The personal name details of the healthcare professional responsible for placing an order, typically in the format of last name, first name, and middle name.
Paper Claim Block	24
Required / Situational	Situational
XML / JSON Field	ord_prov_name_l, ord_prov_name_f, ord_prov_name_m
X12 Loop / Segment	Loop 2420E- NM103, 104, 105
Allowed Values	NDC Code (11 characters), NDC Dosage (7 characters), NDC Measure (2 characters)
Notes	NDC Code References: http://www.accessdata.fda.gov/ https://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=ndc

Fieldname	Ordering Provider NPI / Other ID

Description	A unique 10-digit identification number assigned to healthcare providers in the United States, used for standardizing and uniquely identifying them in electronic transactions.
Paper Claim Block	24
Required / Situational	Situational
XML / JSON Field	ord_prov_npi
X12 Loop / Segment	Loop 2420E- NM109, REF01, REF02
Allowed Values	Numeric 10
Notes

Fieldname	Ordering Provider Address 1 and Address 2:

Description	The street address details of the ordering provider, where "Address 1" and "Address 2" may be used for different address lines if needed.
Paper Claim Block	24
Required / Situational	Situational
XML / JSON Field	ord_prov_addr_1, ord_prov_addr_2
X12 Loop / Segment	Loop 2420E- N301, N302
Allowed Values	Text 55, 55
Notes

Fieldname	Ordering Provider City, State, Zip

Description	The specific location details of the ordering provider, including the city, state, and ZIP code of their practice or location.
Paper Claim Block	24
Required / Situational	Situational
XML / JSON Field	ord_prov_city, ord_prov_state, ord_prov_zip
X12 Loop / Segment	Loop 2420E- NM401, 402, 403
Allowed Values	Text 30, 2, 12
Notes

Field not visible on form

Fieldname	Service Authorization Exception Code
Description	Code indicating the reason for the service being exempt from pre-authorization requirements.
Paper Claim Block	24I
Required / Situational	Situational
XML / JSON Field	chg_prior_auth
X12 Loop / Segment	Loop 2310B - PRV02, REF01 / 2420A - PRV02 REF01
Allowed Values	64 characters
Notes	Not on the electronic form

Fieldname	Rendering Provider Last Name

Description	The last name of the healthcare provider who performed the services or procedures.
Paper Claim Block	24J
Required / Situational	Situational
XML / JSON Field	ref_name_l
X12 Loop / Segment	Loop 2310B - NM1
Allowed Values	35 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Rendering Provider First Name

Description	The first name of the healthcare provider who performed the services or procedures.
Paper Claim Block	24J
Required / Situational	Situational
XML / JSON Field	ref_name_f
X12 Loop / Segment	Loop 2310B - NM1
Allowed Values	25 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Rendering Provider Middle Name

Description	The middle name of the healthcare provider who performed the services or procedures.
Paper Claim Block	24J
Required / Situational	Situational
XML / JSON Field	ref_name_m
X12 Loop / Segment	Loop 2310B - NM1
Allowed Values	25 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Rendering Provider Taxonomy #

Description	The National Provider Identifier (NPI) of the healthcare provider who performed the services or procedures.
Paper Claim Block	24J
Required / Situational	Situational
XML / JSON Field	prov_taxonomy
X12 Loop / Segment	Loop 2310B - PRV03 REF02 / 2420A - PRV03 REF02
Allowed Values	10 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Rendering Provider NPI

Description	The National Provider Identifier (NPI) of the healthcare provider who performed the services or procedures.
Paper Claim Block	24J
Required / Situational	Situational
XML / JSON Field	prov_npi
X12 Loop / Segment	Loop 2310B - PRV03 REF02
Allowed Values	10 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Rendering Provider Atypical ID

Description	Atypical identifier for the rendering provider, if applicable.
Paper Claim Block	24J
Required / Situational	Situational
XML / JSON Field	prov_id
X12 Loop / Segment	Loop 2420A - REF
Allowed Values	32 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Facility Name

Description	The name of the facility where the services were rendered.
Paper Claim Block	24K
Required / Situational	Situational
XML / JSON Field	facility_name
X12 Loop / Segment	Loop 2310E - NM1 (Service Facility Location Name)
Allowed Values	35 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Facility Address 1

Description	The address line 1 of the facility where the services were rendered.
Paper Claim Block	24K
Required / Situational	Situational
XML / JSON Field	facility_addr_1
X12 Loop / Segment	Loop 2310E - N3
Allowed Values	64 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Facility Address 2

Description	The address line 2 of the facility where the services were rendered (if applicable).
Paper Claim Block	24K
Required / Situational	Situational
XML / JSON Field	facility_addr_2
X12 Loop / Segment	Loop 2310E - N3
Allowed Values	64 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Facility City

Description	The city where the facility is located.
Paper Claim Block	24K
Required / Situational	Situational
XML / JSON Field	facility_city
X12 Loop / Segment	Loop 2310E - N4
Allowed Values	35 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Facility State

Description	The state where the facility is located.
Paper Claim Block	24K
Required / Situational	Situational
XML / JSON Field	facility_state
X12 Loop / Segment	Loop 2310E - N4
Allowed Values	Two-letter state codes
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Facility Zip

Description	The ZIP code of the facility where the services were rendered.
Paper Claim Block	24K
Required / Situational	Situational
XML / JSON Field	facility_zip
X12 Loop / Segment	Loop 2310E - N4
Allowed Values	12 characters
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Purchased/Referred Service Name

Description	The name of the provider or entity to whom the services were purchased or referred. This is used when the services listed on the claim were performed by another provider or entity.
Paper Claim Block	24L
Required / Situational	Situational
XML / JSON Field	N/A
X12 Loop / Segment	Loop 2310F - NM1
Allowed Values
Notes	Reference for NPI information: https://npiregistry.cms.hhs.gov/search

Fieldname	Code (Primary Patient Adjustment Code)

Description	The adjustment reason codes communicate to the secondary or tertiary payers what the primary or secondary payers did not pay when they adjudicated the claim. These are the equivalent of sending an electronic EOB.
Paper Claim Block	Note: The dropdown on the top must be on SECONDARY, to see the adjustment code fields. This line will display under line 24 A-G.
Required / Situational	Situational
XML / JSON Field	adj_code_1 adj_cod 2, adj_cod_3, adj_cod_4, adj_code, 5, adj_code_6, adj_code_7, adj_code_8
X12 Loop / Segment	N/A
Allowed Values	6 characters
Notes	The adjustment should be used from the previous payers EOB, but the full list can be found here: https://x12.org/codes/claim-adjustment-reason-codes

Fieldname	Amount (Primary Patient Adjustment Amount)

Description	The adjustment amount is the difference between the total billed charges for medical services and the amount paid by the primary insurance provider, which may be covered by a secondary insurance plan or paid out-of-pocket by the patient.
Paper Claim Block	Note: The dropdown on the top must be on SECONDARY, to see the adjustment code fields. This line will display under line 24 A-G.
Required / Situational	Situational
XML / JSON Field	adj_amt_1, adj_amt_2, adj_amt_3, adj_amt_4, adj_amt_5, adj_amt_6, adj_amt_7, adj_amt_8
X12 Loop / Segment	N/A
Allowed Values	Numeric 8.2
Notes

Fieldname	Remit Date

Description	The remit date is the date on which the insurance company or payer issues the payment or explanation of benefits (EOB) for a claim, detailing the adjustments made to the billed charges and the amount the provider will receive.
Paper Claim Block	Note: The dropdown on the top must be on SECONDARY, to see the adjustment code fields. This line will display under line 24 A-G.
Required / Situational	Situational
XML / JSON Field	primary_paid_date
X12 Loop / Segment	N/A
Allowed Values	date mmddyy
Notes

Fieldname	Paid (Primary Paid Amount)

Description	The amount paid by the primary (or if tertiary claim, the secondary) payer.
Paper Claim Block	Note: The dropdown on the top must be on SECONDARY (or tertiary), to see the adjustment code fields. This line will display under line 24 A-G.
Required / Situational	Situational
XML / JSON Field	primary_paid_amount_2
X12 Loop / Segment
Allowed Values	date mmddyy
Notes

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

Fieldname	Federal Tax ID Number

Description	The Federal Tax Identification Number (TIN) of the billing provider or the facility.
Paper Claim Block	25
Required / Situational	Required for group or facility billing, Situational for individual providers
XML / JSON Field	bill_taxid
X12 Loop / Segment	Loop 2300 - CLM01
Allowed Values	16 characters
Notes	EIN is for "Employment Identification Number" is generally used for identifying a business/organization. SSN is for Social Security Number and selected for identifying individual providers.

Fieldname	Patient's Account Number

Description	The patient's account number or identifier used by the billing provider to track the patient's billing and financial information. This is a number decided by the biller or a billing software system.
Paper Claim Block	26
Required / Situational	Required
XML / JSON Field	pcn
X12 Loop / Segment	Loop 2300 - CLM07
Allowed Values	1 character "YES" or "NO."
Notes	This is either decided by the biller (usually following a convention) or generated from a PMS/EMR system

Fieldname	Accept Assignment

Description	Indication of whether the billing provider accepts assignment of the claim or not. If "YES," it means the provider accepts the approved charge determined by the payer. If "NO," it means the provider does not accept the approved charge and may bill the patient.
Paper Claim Block	27
Required / Situational	Required
XML / JSON Field	accept_assign
X12 Loop / Segment	Loop 2300 - CLM07
Allowed Values	1 character "YES" or "NO."
Notes

Fieldname	Total Charge

Description	The total charge for all services rendered to the patient.
Paper Claim Block	28
Required / Situational	Required
XML / JSON Field	total_charge
X12 Loop / Segment	Loop 2300 - CLM02
Allowed Values	12.2
Notes

Fieldname	Amount Paid

Description	The total amount paid by the primary payer.
Paper Claim Block	29
Required / Situational	Situational
XML / JSON Field	amount_paid
X12 Loop / Segment	Loop 2300 (patient amount paid) , 2320 (payer amount paid) - AMT02
Allowed Values	Numeric 8.2
Notes

Fieldname	Balance Due

Description	The amount remaining to be paid by the patient after considering the total charges, primary payer's payment, and any adjustments or deductions.
Paper Claim Block	30
Required / Situational	Situational
XML / JSON Field	balance_due
X12 Loop / Segment
Allowed Values
Notes

Professional Claim- Block 31
Rendering Provider Information

Fieldname	Rendering Provider Last Name

Description	The last name or surname of the rendering healthcare provider who performed or provided the healthcare services.
Paper Claim Block	31
Required / Situational	Required
XML / JSON Field	prov_name_l
X12 Loop / Segment	Loop 2310B - NM1
Allowed Values	35 characters
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Rendering Provider First Name

Description	The first name or given name of the rendering healthcare provider who performed or provided the healthcare services.
Paper Claim Block	31
Required / Situational	Required
XML / JSON Field	prov_name_f
X12 Loop / Segment	Loop 2310B - NM1 (Name)
Allowed Values	25 characters
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Rendering Provider Middle Name

Description	The middle name or initial of the rendering healthcare provider who performed or provided the healthcare services.
Paper Claim Block	31
Required / Situational	Situational
XML / JSON Field	prov_name_m
X12 Loop / Segment	Loop 2310B - NM1 (Name)
Allowed Values	25 characters
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Rendering Provider NPI

Description	The National Provider Identifier (NPI) number assigned to the rendering healthcare provider.
Paper Claim Block	31
Required / Situational	Required
XML / JSON Field	prov_npi
X12 Loop / Segment	Loop 2310B - NM1
Allowed Values	Numeric 10 characters digits representing the unique NPI number assigned to the rendering provider by the National Plan and Provider Enumeration System (NPPES).
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Rendering Provider Atypical ID

Description	The unique identification number or code assigned to the rendering healthcare provider by their practice or facility.
Paper Claim Block	N/A (Not applicable as this field is not part of the standard CMS-1500 (02/12) paper claim form.)
Required / Situational	Situational
XML / JSON Field	prov_id
X12 Loop / Segment	N/A (Not applicable as this field is not part of the standard X12 EDI format for electronic claim submissions based on the CMS-1500 form.)
Allowed Values	32 characters
Notes	The "Provider ID" is not a standard field on the CMS-1500 (02/12) form. If such information is required for a specific claim submission, it may need to be provided as part of supplemental documentation or data accompanying the standard CMS-1500 form. Always check with the insurance payer or electronic claims processing system for any additional data requirements or specific guidelines related to this field.

Professional Claim- Block 32
Facility Information

Fieldname	Service Facility Location Name

Description	The name of the facility or location where the services were rendered.
Paper Claim Block	32
Required / Situational	Situational
XML / JSON Field	facility_name
X12 Loop / Segment	Loop 2310C -NM103 N403
Allowed Values	32 characters
Notes

Fieldname	Service Facility Location Address

Description	The address of the facility or location where the services were rendered.
Paper Claim Block	32
Required / Situational	Situational
XML / JSON Field	facility_addr_1
X12 Loop / Segment	Loop 2310E - N301
Allowed Values	64 characters
Notes

Fieldname	Service Facility Location City

Description	The city where the facility or location is located.
Paper Claim Block	32
Required / Situational	Situational
XML / JSON Field	facility_city
X12 Loop / Segment	Loop 2310E - N401
Allowed Values	32 characters
Notes

Fieldname	Service Facility Location State

Description	The state where the facility or location is located.
Paper Claim Block	32
Required / Situational	Situational
XML / JSON Field	facility_state
X12 Loop / Segment	Loop 2310E - N402
Allowed Values	Two-letter state codes (e.g., CA, NY, TX).
Notes

Fieldname	Service Facility Location ZIP Code

Description	The ZIP code of the facility or location where the services were rendered.
Paper Claim Block	32
Required / Situational	Situational
XML / JSON Field	facility_zip
X12 Loop / Segment	Loop 2310E - N403 (Service Facility Location City, State, ZIP Code)
Allowed Values	12 characters
Notes

Fieldname	Facility NPI

Description	The National Provider Identifier (NPI) number assigned to the facility or institution where the healthcare services were rendered or performed.
Paper Claim Block	32a
Required / Situational	Situational (If applicable to the claim, the Facility NPI is required.)
XML / JSON Field	facility_npi
X12 Loop / Segment	Loop 2310C - NM109
Allowed Values	Numeric 10 - Numeric digits representing the unique NPI number assigned to the facility or institution by the National Plan and Provider Enumeration System (NPPES).
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Facility ID

Description	The unique identification number assigned to the facility or institution where the healthcare services were rendered or performed.
Paper Claim Block	32b
Required / Situational	Situational (If applicable to the claim, the Facility ID is required.)
XML / JSON Field	facility_id
X12 Loop / Segment	Loop 2310C - REF01, REF02
Allowed Values	32 characters - Alphanumeric characters, spaces, and special characters representing the facility's unique identification number or code.
Notes	The Facility ID is used to uniquely identify the specific facility or institution where the healthcare services were provided. It may be required by certain payers or electronic claims processing systems for claims adjudication and billing purposes. Providers should use the correct Facility ID when submitting claims to ensure accurate processing and reimbursement.

Professional Claim- Block 33
Billing Provider Information

Fieldname	Billing Provider Name

Description	The name of the billing provider or the entity responsible for submitting the claim. This could be an individual provider's name or the name of a group practice or facility.
Paper Claim Block	33
Required / Situational	Required
XML / JSON Field	bill_name
X12 Loop / Segment	Loop 2010AA - NM103
Allowed Values	32 characters
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Billing Provider Address

Description	The address of the billing provider or the entity responsible for submitting the claim. Please note: PO Boxes are NOT allowed for primary or secondary billing provider addresses.
Paper Claim Block	33
Required / Situational	Required
XML / JSON Field	bill_addr_1
X12 Loop / Segment	Loop 2010AA - NM301
Allowed Values	128 characters
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Billing Provider City

Description	The city where the billing provider is located.
Paper Claim Block	33
Required / Situational	Required
XML / JSON Field	bill_city
X12 Loop / Segment	Loop 2010AA - NM401
Allowed Values	32 characters
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Billing Provider State

Description	The state where the billing provider is located.
Paper Claim Block	33
Required / Situational	Required
XML / JSON Field	bill_state
X12 Loop / Segment	Loop 2010AA - 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

Fieldname	Billing Provider ZIP Code

Description	The ZIP code of the billing provider's location.
Paper Claim Block	33
Required / Situational	Required
XML / JSON Field	bill_zip
X12 Loop / Segment	Loop 2010AA - NM403
Allowed Values	12 characters
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Billing Provider Phone Number
Field not in claim form
Description	The phone number of the billing provider or the entity submitting the claim. This can include the area code.
Paper Claim Block	33
Required / Situational	Required
XML / JSON Field	bill_phone
X12 Loop / Segment	Loop 2010AA - PER
Allowed Values	16 characters
Notes	Not on the electronic form. Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Billing Provider NPI

Description	The National Provider Identifier assigned to a healthcare provider for the purpose of processing and tracking medical claims.
Paper Claim Block	33a
Required / Situational	Required
XML / JSON Field	bill_npi
X12 Loop / Segment	Loop 2010AA / NM109
Allowed Values	10 characters
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Billing Provider Taxonomy

Description	The code that specifies the type or classification of healthcare services provided by the billing provider.
Paper Claim Block	33b
Required / Situational	Situational
XML / JSON Field	bill_taxonomy
X12 Loop / Segment	Loop 2000A - PRV03 / 2010AA - REF01, REF02
Allowed Values	10 characters - representing the specific taxonomy code assigned to the billing provider by relevant healthcare authorities or organizations.
Notes	Provider information. Review for accuracy if needed: https://npiregistry.cms.hhs.gov/search

Fieldname	Billing Provider ID

Description	The unique identification number or code assigned to the billing healthcare provider or organization by their practice or facility.
Paper Claim Block	33b
Required / Situational	Situational (Required if this is used instead of NPI)
XML / JSON Field	bill_id
X12 Loop / Segment	Loop 2010BB, REF*G2
Allowed Values	32 characters
Notes	The "Billing Provider ID" is not a standard field on the CMS-1500 (02/12) form. If such information is required for a specific claim submission, it may need to be provided as part of supplemental documentation or data accompanying the standard CMS-1500 form. Always check with the insurance payer or electronic claims processing system for any additional data requirements or specific guidelines related to this field.

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Facility Claim Form Overview

Table of contents

Professional Claim Form Overview

Payer Name

Payer ID

Payer Address

Payer Address 2

Payer City

Payer State

Payer Zip Code

Insured I.D. Number

Patient Name

Patient Date of Birth

Patient Sex

Insured's Name

Patient Address

Patient Address 2

Patient City

Patient State

Patient Zip Code

Patient Country Code

Patient Phone Number

Patient Relationship

Insured's Address

Insured's Address 2

Insured's City

Insured's State

Insured Zip

Insured Country Code

Insured Phone Number

Marital and Work Status

Secondary Insured Last Name

Secondary Insured First Name

Secondary Insured's Middle Name

Secondary Insured's Policy Number

Secondary Insured's Date of Birth

Secondary Insured's Sex

Secondary Payment Date

Secondary Payer's Name

Secondary Insurance Payer ID

Secondary Payer's Claim ID

Secondary Payer Address 1

Secondary Payer Address 2

Secondary Payer City

Secondary Payer State

Secondary Payer Zip

Medicare Type Code

Secondary Policy Relationship

Secondary Policy Group Name

Secondary Policy Number

Accident Related to Employment

Accident Related to Auto

Auto Accident State

Other Accident Related

Condition Code (1, 2, 3)

Insured's Policy Group

Insured Date of Birth

Insured Gender

Insured Employer Name/School Name/ Other Claim ID

Insured Plan Name

Supervisor Name / ID / NPI

Date of Condition / Date of Current illness, injury, pregnancy (LMP)

Date of Onset

Date Last Seen

Unable to Work From Date

Unable to Work To Date

Referring Provider Last Name

Referring Provider First Name

Referring Provider Middle Name

Referring Provider NPI

Referring Provider Atypical ID

Hospital Admit Date / Dates Related to Current Services

Hospital Discharge Date

Chiro Condition Manifest Date

Diagnoses Code A

Medicaid Resubmission Code

Prior Authorization Number

Referral Number