Claim Form Manual - Geisinger Health Plan

National Uniform Claim Committee
NUCC
TM
National Uniform Claim Committee
1500 Health Insurance Claim Form
Reference Instruction Manual
For Form Version 08/05
July 2008
Version 4.0 07/08
Disclaimer and Notices
© 2008 American Medical Association
This document is published in cooperation with the National Uniform Claim Committee (NUCC) by the American
Medical Association (AMA). Permission is granted to any individual to copy and distribute this material as long as the
copyright statement is included, the contents are not changed, and the copies are not sold or licensed. Applicable
FARS/DFARS restrictions apply.
The 1500 Health Insurance Claim Form is in the public domain.
The NUCC has developed this general instructions document for completing the 1500 Health Insurance Claim Form.
This document is intended to be a guide for completing the 1500 Claim Form and not definitive instructions for this
purpose. Any user of this document should refer to the most current federal, state, or other payer instructions for
specific requirements applicable to using the 1500 Claim Form.
The NUCC Reference Instruction Manual must remain intact. Any payer-specific or other organization-specific
instructions for completion of the 1500 Claim Form need to be maintained in a separate document.
The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other
professional advice or recommendations by the AMA or the NUCC. You should consult with an appropriate professional if
you need legal or other advice. The listing of an organization or the provision of a link to a web site does not imply any
endorsement by the AMA or the NUCC or by any of its members for the products, services, and/or Internet sites listed.
This document is provided “as is” without representation or warranty of any kind either express or implied. The AMA and
the NUCC and its members shall not be responsible for any use or non use of this document.
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TABLE OF CONTENTS
Page
Background Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Sample 1500 Claim Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Overall Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Field Specific Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Carrier Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Items 1-13: Patient and Insured Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Items 14-33: Provider or Supplier Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Appendix A: Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Appendix B: Guidelines for Modifying the 1500 (08/05) Claim Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Appendix C: Maintenance of the 1500 Reference Instruction Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
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1500 CLAIM FORM INSTRUCTIONS: BACKGROUND INFORMATION
The 1500 Health Insurance Claim Form answers the needs of many health payers. It is the basic paper claim
form prescribed by many health plans for claims submitted by physicians and suppliers, and in some cases, for
ambulance services.
In the 1960s there were a number of different claim forms and coding systems required by third-party payers
to communicate information regarding procedures and services to agencies concerned with insurance claims.
However, there was no standardized form for physicians and other health care providers to report health care
services. Therefore, the American Medical Association (AMA) embraced an assignment in the 1980s to work
with the Centers for Medicare & Medicaid Services (CMS; formerly known as HCFA), and many other payer
organizations through a group called the Uniform Claim Form Task Force to standardize and promote the use
of a universal health claim form. As a result of this joint effort, the 1500 Claim Form is accepted nationwide
by most insurance entities as the standard claim form/attending physician statement for submission of
medical claims.
With the transition to an increase in electronic claims submission and the Health Insurance Portability and
Accountability Act (HIPAA) regulations, the Uniform Claim Form Task Force was replaced by the National
Uniform Claim Committee (NUCC) in the mid 1990s. The NUCC’s goal was to develop the NUCC Data Set
(NUCC-DS), a standardized data set for use in an electronic environment, but applicable to and consistent
with evolving paper claim form standards. The NUCC continues to be responsible for the maintenance of the
1500 Claim Form. After considerable research to determine if the claim form needed updating in the late
1990s, the NUCC determined that the cost to implement any changes to the form at that time would exceed
any projected gains.
Although many providers now submit electronic claims, many of their software/hardware systems depend on
the existing 1500 Claim Form in its current image. Minor changes have been made to the form in order to
accommodate the National Provider Identifier (NPI) as well as other identifiers.
The following 1500 Claim Form instructions were approved by the NUCC in November, 2005. The NUCC will
continue to research the type of data that are typically reported in the “reserved for local use” fields as well as
the required data elements in the other fields that may apply to public and private payers. Therefore, the
instructions will continue to evolve. The ultimate goal of the NUCC is to develop standardized national
instructions. The end result may require additional changes to the 1500 Claim Form in the future.
The instructions in this manual are not specific to any applicable public or private payer.
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OVERALL INSTRUCTIONS
Each Item Number includes the title, instructions, description, field specifications, and example. The examples provided in the instructions are demonstrating how to enter the data in the field. They are not providing
instruction on how to bill for certain services.
Punctuation
The use of punctuation is noted in the instructions section of each Item Number.
Multiple Page Claims
When reporting line item services on multiple page claims, only the diagnosis code(s) reported on the first
page may be used and must be repeated on subsequent pages. If more than four diagnoses are required to
report the line services, the claim must be split and the services related to the additional diagnoses must be
billed as a separate claim.
Please note: Form images throughout this manual may not be to scale.
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FIELD SPECIFIC INSTRUCTIONS
CARRIER BLOCK
The carrier block is located in the upper right margin of the form. A bar code that existed on some forms in
the upper left margin has been eliminated. In order to distinguish this version from previous versions, the
1500 symbol and the date approved by the NUCC has been added to the top margin.
Instructions: Enter in the white, open carrier area the name and address of the payer to whom this claim is
being sent. Enter the name and address information in the following format:
1st Line – Name
2nd Line – First line of address
3rd Line – Second line of address
4th Line – City, State (2 characters) and ZIP Code
Line
4
5
6
7
Descriptor
Payer Name
Payer Address 1
Payer Address 2
Payer City State and ZIP
Type
A/N
A/N
A/N
A/N
Bytes
41
41
41
41
Columns
38-78
38-78
38-78
38-78
For an address with three lines, enter it in the following format:
1st Line – Name
2nd Line – Line of address
3rd Line – Leave blank
4th Line – City, State (2 characters) and ZIP Code
Line
4
5
6
7
Descriptor
Payer Name
Payer Address
Leave blank
Payer City State and ZIP
Type
A/N
A/N
Bytes Columns
41
38-78
41
38-78
A/N
41
38-78
Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123
N. Main Street, #101). When entering a 9 digit ZIP code, include the hyphen.
When printing page numbers on multiple page claims (general done by clearinghouses when converting the
837P 4010A1 to the 1500 Claim Form), print the page numbers in the Carrier Block on Line 8 beginning at
column 32. Page numbers are to be printed as:
Page XX of YY
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Description: The payer is the carrier, health plan, third-party administrator, or other payer who will handle
the claim. This information directs the claim to the appropriate payer.
Example:
Four line address:
ABC Insurance Company
Suite 600
567 Insurance Lane
Big City, IL 60605
Page 01 of 02
Three line address:
ABC Insurance Company
567 Insurance Lane
Big City, IL 60605
Page 01 of 02
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ITEMS 1–13: PATIENT AND INSURED INFORMATION
Item Number 1
Title: Medicare, Medicaid, TRICARE CHAMPUS, CHAMPVA, Group Health Plan, FECA, Black Lung, Other
Instructions: Indicate the type of health insurance coverage applicable to this claim by placing an X in the
appropriate box. Only one box can be marked.
Description: Medicare, Medicaid, TRICARE CHAMPUS, CHAMPVA, Group Health Plan, FECA, Black Lung,
or Other means the insurance type to whom the claim is being submitted. Other indicates health insurance
including HMOs, commercial insurance, automobile accident, liability, or workers’ compensation. This
information directs the claim to the correct program and may establish primary liability.
Field Specifications: This field allows for entry of 1 character in any box within the field.
Example:
x
Item Number 1a
Title: Insured’s ID Number
Instructions: Enter insured’s ID number as shown on insured’s ID card for the payer to whom the claim is
being submitted.
For Workers Compensation: Enter the Employee ID
Description: The insured’s ID number is the identification number of the person who holds the policy or the
dependent patient if they have been issued a unique identifier by the payer. This information identifies the
patient to the payer.
Field Specification: This field allows for entry of 29 characters.
Example:
x0123456789
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Item Number 2
Title: Patient’s Name
Instructions: Enter the patient’s full last name, first name, and middle initial. If the patient uses a last name
suffix (e.g., Jr, Sr) enter it after the last name, and before the first name. Titles (e.g., Sister, Capt, Dr) and
professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.
Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated
names. Do not use periods within the name.
Description: The patient’s name is the name of the person who received the treatment or supplies.
Field Specification: This field allows for the entry of 28 characters.
Example:
Doe Jr, John, J
Item Number 3
Title: Patient’s Birth Date, Sex
Instructions: Enter the patient’s 8-digit birth date (MM | DD | CCYY). Enter an X in the correct box to
indicate sex of the patient. Only one box can be marked. If gender is unknown, leave blank.
Description: The patient’s birth date and sex (gender) is information that will identify the patient and it
distinguishes persons with similar names.
Field Specification: This field allows for the entry of the following: 2 characters under MM, 2 characters
under DD, 4 characters under YY, and 1 character in either box.
Example:
01
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x
10
Item Number 4
Title: Insured’s Name
Instructions: Enter the insured’s full last name, first name, and middle initial. If the insured uses a last name
suffix (e.g., Jr, Sr) enter it after the last name, and before the first name. Titles (e.g., Sister, Capt, Dr) and
professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.
Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated
names. Do not use periods within the name.
For Workers Compensation: Enter the name of the Employer.
Description: The insured’s name identifies the person who holds the policy, which would be the employee for
employer-provided health insurance.
Field Specification: This field allows for the entry of 29 characters.
Example:
Doe, John, J
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Item Number 5
Title: Patient’s Address (multiple fields)
Instructions: Enter the patient’s mailing address and telephone number. The first line is for the street
address; the second line, the city and state; the third line, the ZIP code and phone number. Patient’s
Telephone does not exist in the electronic 837 Professional 4010A1.
Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123
N. Main Street, #101). When entering a 9 digit ZIP code, include the hyphen. Do not use a hyphen or space as
a separator within the telephone number.
If a foreign address, contact payer for specific reporting instructions.
Description: The patient’s address refers to the patient’s permanent residence. A temporary address or school
address should not be used.
Field Specification: This field allows for the entry of the following: 28 characters for street address, 24 characters for city, 3 characters for state, 12 characters for ZIP code, 3 characters for area code, and 10 characters
for phone number.
Example:
123 Main Street
Anytown
60610
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312 5551212
12
Item Number 6
Title: Patient Relationship to Insured
Instructions: Enter an X in the correct box to indicate the patient’s relationship to insured when Item
Number 4 is completed. Only one box can be marked.
Description: The patient relationship to insured refers to how the patient is related to the insured. Self would
indicate that the insured is the patient. Spouse would indicate that the patient is the husband or wife or
qualified partner as defined by the insured’s plan. Child would indicate that the patient is the minor dependent as defined by the insured’s plan. Other would indicate that the patient is other than the self, spouse, or
child, which may include employee, ward, or dependent as defined by the insured’s plan.
Field Specification: This field allows for entry of 1 character in any box within the field.
Example:
x
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Item Number 7
Title: Insured’s Address (multiple fields)
Instructions: Enter the insured’s address and telephone number. If Item Number 4 is completed then this
field should be completed. The first line is for the street address; the second line, the city and state; the third
line, the ZIP code and phone number. Insured’s Telephone does not exist in the electronic 837 Professional
4010A1.
Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123
N. Main Street, #101). When entering a 9 digit ZIP code, include the hyphen. Do not use a hyphen or space as
a separator within the telephone number.
For Workers Compensation: Enter the address of the Employer.
Description: The insured’s address refers to the insured’s permanent residence, which may be different from
the patient’s address in Item Number 5.
Field Specification: This field allows for the entry of the following: 29 characters for street address, 23 characters for city, 4 characters for state, 12 characters for ZIP code, 3 characters for area code, and 10 characters
for phone number.
Example:
123 Main Street
Anytown
60610
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312 5551212
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Item Number 8
Title: Patient Status
Instructions: Patient Status does not exist in the electronic 837 Professional 4010A1.
Enter an X in the box for the patient’s marital status, and for the patient’s employment or student status.
Only one box on each line can be marked.
Description: The patient status indicates the patient’s marital and employment status. Employed would indicate that the patient has a job. Full-time student would indicate that the patient is registered as a full-time
student as defined by the post-secondary school or university. Part-time student would indicate that the
patient is registered as a part-time student as defined by the post-secondary school or university. This information is important for determination of liability and coordination of benefits (COB).
Field Specification: This field allows for entry of 1 character in any box within the field.
Example:
x
x
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Item Number 9
Title: Other Insured’s Name
Instructions: If Item Number 11d is marked, complete fields 9 and 9a-d, otherwise leave blank. When additional group health coverage exists, enter other insured’s full last name, first name, and middle initial of the
enrollee in another health plan if it is different from that shown in Item Number 2. If the insured uses a last
name suffix (e.g., Jr, Sr) enter it after the last name, and before the first name. Titles (e.g., Sister, Capt, Dr)
and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.
Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated
names. Do not use periods within the name.
Description: The other insured’s name indicates that there is a holder of another policy that may cover the
patient.
Field Specification: This field allows for the entry of 28 characters.
Example:
Doe, Mary, A
Item Number 9a
Title: Other Insured’s Policy or Group Number
Instructions: Enter the policy or group number of the other insured.
Do not use a hyphen or space as a separator within the policy or group number.
Description: The other insured’s policy or group number identifies the policy or group number for coverage of
the insured as indicated in Item Number 9.
Field Specification: This field allows for the entry of 28 characters.
Example:
x9876543210
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Item Number 9b
Title: Other Insured’s Date of Birth, Sex
Instructions: Enter the 8-digit date of birth (MM | DD | CCYY) of the other insured and an X to indicate the
sex of the other insured. Only one box can be marked. If gender is unknown, leave blank.
Description: The other insured’s date of birth and sex (gender) identifies the birth date and gender of the
insured as indicated in Item Number 9.
Field Specification: This field allows for the entry of the following: 2 characters under MM, 2 characters
under DD, 4 characters under YY, and 1 character in either box.
Example:
01
01 1960
x
Item Number 9c
Title: Employer’s Name or School Name
Instructions: Employer’s Name and School Name do not exist in the electronic 837 Professional 4010A1.
Enter the name of the other insured’s employer or school.
Description: The employer’s name or school name identifies the name of the employer or school attended by
the other insured as indicated in Item Number 9.
Field Specification: This field allows for the entry of 28 characters.
Example:
Community Hospital
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Item Number 9d
Title: Insurance Plan Name or Program Name
Instructions: Enter the other insured’s insurance plan or program name.
Description: The insurance plan name or program name identifies the name of the plan or program of the
other insured as indicated in Item Number 9.
Field Specification: This field allows for the entry of 28 characters.
Example:
XYZ Insurance Company
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Item Numbers 10a–10c
Title: Is Patient’s Condition Related To:
Instructions: When appropriate, enter an X in the correct box to indicate whether one or more of the services
described in Item Number 24 are for a condition or injury that occurred on the job or as a result of an automobile or other accident. Only one box on each line can be marked.
The state postal code must be shown if "YES" is marked in 10b for "Auto Accident." Any item marked "YES"
indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Item Number 11.
Description: This information indicates whether the patient’s illness or injury is related to employment, auto
accident, or other accident. Employment (current or previous) would indicate that the condition is related to
the patient’s job or workplace. Auto accident would indicate that the condition is the result of an automobile
accident. Other accident would indicate that the condition is the result of any other type of accident.
Field Specification: This field allows for the entry of the following: 1 character in either box per each line
and 2 characters in the Place/State field
Example:
x
x
x
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Item Number 10d
Title: Reserved for Local Use
Instructions: Please refer to the most current instructions from the applicable public or private payer
regarding the use of this field.
When required by payers to provide a sub-set of Condition Codes approved by the NUCC, enter the Condition
Code in this field. Use the qualifier BG to indicate that the code being reported is a Condition Code. Enter
the Condition Code in the following order: qualifier, Condition Code, e.g., BGAD or BGW2. The Condition
Codes approved for use on the 1500 Claim Form are available at www.nucc.org under Code Sets.
For Workers Compensation: Condition Codes are required when submitting a bill that is a duplicate or an
appeal. (Original Reference Number must be entered in Box 22 for these conditions). Note: Do not use
Condition Codes when submitting a revised or corrected bill.
Field Specification: This field allows for the entry of 19 characters.
Example: None
Item Number 11
Title: Insured’s Policy, Group, or FECA Number
Instructions: Enter the insured’s policy or group number as it appears on the insured’s health care
identification card. If Item Number 4 is completed, then this field should be completed.
Do not use a hyphen or space as a separator within the policy or group number.
For Workers Compensation: Required if known. Enter Workers’ Compensation Claim Number assigned by
the payer.
Description: The insured’s policy, group, or FECA number refers to the alphanumeric identifier for the
health, auto, or other insurance plan coverage. The FECA number is the 9-digit alphanumeric identifier
assigned to a patient claiming work-related condition(s) under the Federal Employees Compensation Act 5
USC 8101.
Field Specification: This field allows for the entry of 29 characters.
Example:
A1234
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Item Number 11a
Title: Insured’s Date of Birth, Sex
Instructions: Enter the 8-digit date of birth (MM | DD | CCYY) of the insured and an X to indicate the sex of
the insured. Only one box can be marked. If gender is unknown, leave blank.
Description: The insured’s date of birth and sex (gender) refers to the birth date and gender of the insured
as indicated in Item Number 1a.
Field Specification: This field allows for the entry of the following: 2 characters under MM, 2 characters
under DD, 4 characters under YY, and 1 character in either box.
Example:
01
01 1958
x
Item Number 11b
Title: Insured’s Employer’s Name or School Name
Instructions: Employer’s Name and School Name do not exist in the electronic 837 Professional 4010A1.
Enter the name of the insured’s employer or school.
Description: The insured’s employer’s name or school name refers to the name of the employer or school
attended by the insured as indicated in Item Number 1a.
Field Specification: This field allows for the entry of 29 characters.
Example:
Local Company
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Item Number 11c
Title: Insurance Plan Name or Program Name
Instructions: Enter the insurance plan or program name of the insured. Some payers require an
identification number of the primary insurer rather than the name in this field.
Description: The insurance plan name or program name refers to the name of the plan or program of
the insured as indicated in Item Number 1a.
Field Specification: This field allows for the entry of 29 characters.
Example:
ABC Insurance Company
Item Number 11d
Title: Is there another Health Benefit Plan?
Instructions: When appropriate, enter an X in the correct box. If marked "YES", complete 9 and 9a–d.
Only one box can be marked.
Description: "Is there another health benefit plan" indicates that the patient has insurance coverage other
than the plan indicated in Item Number 1.
Field Specification: This field allows for the entry of 1 character in either box.
Example:
x
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Item Number 12
Title: Patient’s or Authorized Person’s Signature
Instructions: Enter "Signature on File," "SOF," or legal signature. When legal signature, enter date signed in 6
digit format (MMDDYY) or 8-digit format (MMDDCCYY). If there is no signature on file, leave blank or enter
"No Signature on File."
Description: The patient’s or authorized person’s signature indicates there is an authorization on file for the
release of any medical or other information necessary to process and/or adjudicate the claim.
Field Specification: Use the space available to enter signature/information and date.
Example:
SOF
Item Number 13
Title: Insured’s or Authorized Person’s Signature
Instructions: Enter "Signature on File," "SOF," or legal signature. If there is no signature on file,
leave blank or enter "No Signature on File."
Description: The insured’s or authorized person’s signature indicates that there is a signature on file
authorizing payment of medical benefits.
Field Specification: Use the space available to enter signature/information.
Example:
SOF
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ITEMS 14–33: PROVIDER OR SUPPLIER INFORMATION
Item Number 14
Title: Date of Current Illness, Injury, Pregnancy
Instructions: Enter the 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) date of the first date of the
present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as
the first date.
Description: The date of current illness, injury, pregnancy refers to the first date of onset of illness, the
actual date of injury, or the LMP for pregnancy.
Field Specification: This field allows for the entry of the following: 2 characters under MM, 2 characters
under DD, and 4 characters under YY.
Example:
09
30 2005
Item Number 15
Title: If Patient Has Had Same or Similar Illness
Instructions: Enter the first date the patient had the same or a similar illness. Enter the date in the 6-digit
format (MM | DD | YY) or 8-digit format (MM | DD | CCYY). Previous pregnancies are not a similar illness.
Leave blank if unknown.
Description: A patient having had same or similar illness would indicate that the patient had a previously
related condition.
Field Specification: This field allows for the entry of the following: 2 characters under MM, 2 characters
under DD, and 4 characters under YY.
Example:
09 25 2005
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Item Number 16
Title: Dates Patient Unable to Work in Current Occupation
Instructions: If the patient is employed and is unable to work in current occupation, a 6-digit (MM | DD | YY)
or 8-digit (MM | DD | CCYY) date must be shown for the "from–to" dates that the patient is unable to work.
An entry in this field may indicate employment-related insurance coverage.
Description: Dates patient unable to work in current occupation would refer to the time span the patient is
or was unable to work.
Field Specification: This field allows for the entry of the following in each of the date fields: 2 characters
under MM, 2 characters under DD, and 4 characters under YY.
Example:
09 25 2005
10 28 2005
Item Number 17
Title: Name of Referring Provider or Other Source
Instructions: Enter the name (First Name, Middle Initial, Last Name) and credentials of the professional
who referred, ordered, or supervised the service(s) or supply(ies) on the claim.
If multiple providers are involved, enter one provider using the following priority order:
1. Referring Provider
2. Ordering Provider
3. Supervising Provider
Do not use periods or commas within the name. A hyphen can be used for hyphenated names.
Description: The name is the referring provider, ordering provider, or supervising provider who referred,
ordered, or supervised the service(s) or supply(s) on the claim.
Field Specification: This field allows for the entry of 26 characters.
Example:
Jane A Smith MD
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Item Number 17a and 17b (split field)
Title 17a: Other ID#
Instructions 17a: The Other ID number of the referring, ordering, or supervising provider is reported in 17a
in the shaded area. The qualifier indicating what the number represents is reported in the qualifier field to
the immediate right of 17a. The NUCC defines the following qualifiers, since they are the same as those used
in the electronic 837 Professional 4010A1:
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
X5
ZZ
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer’s Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number (The social security number may not be used for Medicare.)
State Industrial Accident Provider Number
Provider Taxonomy
The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identifiers are assigned to the provider either by a specific payer or by a third party in order to uniquely identify the
provider. The taxonomy code is designated by the provider in order to identify his/her provider type, classification, and/or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.
Description: The non-NPI ID number of the referring, ordering, or supervising provider refers to the unique
identifier of the professional or to the provider designated taxonomy code.
Field Specification: This field allows for the entry of 2 characters in the qualifier field and 17 characters in
the Other ID# field.
Title 17b: NPI #
Instructions 17b: Enter the NPI number of the referring, ordering, or supervising provider in Item Number 17b.
Description: The NPI number refers to the HIPAA National Provider Identifier number.
Field Specification: This field allows for the entry of a 10 digit NPI number.
Example:
1B ABC1234567890
0123456789
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Item Number 18
Title: Hospitalization Dates Related to Current Services
Instructions: Enter the inpatient 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) hospital admission date
followed by the discharge date (if discharge has occurred). If not discharged, leave discharge date blank.
This date is when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Description: The hospitalization dates related to current services would refer to an inpatient stay and
indicates the admission and discharge dates associated with the service(s) on the claim.
Field Specification: This field allows for the entry of the following in each of the date fields: 2 characters
under MM, 2 characters under DD, and 4 characters under YY.
Example:
09 25 2005
09 28 2005
Item Number 19
Title: Reserved for local use
Instructions: Please refer to the most current instructions from the applicable public or private payer regarding the use of this field. Some payers ask for certain identifiers in this field. If identifiers are reported in this
field, enter the appropriate qualifiers describing the identifier. Do not enter a space, hyphen, or other separator between the qualifier code and the number. The NUCC defines the following qualifiers, since they are the
same as those used in the electronic 837 Professional 4010A1:
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
X5
ZZ
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer’s Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number (The social security number may not be used for Medicare.)
State Industrial Accident Provider Number
Provider Taxonomy
The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identifiers are assigned to the provider either by a specific payer or by a third party in order to uniquely identify the
provider. The taxonomy code is designated by the provider in order to identify his/her provider type, classification, and/or area of specialization. Both, provider identifiers and provider taxonomy may be used in this
field.
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When reporting a second item of data, enter three blank spaces and then the next qualifier and
number/code/information.
For Workers’ Compensation: Required based on Jurisdictional Workers’ Compensation Guidelines.
When reporting Supplemental Claim Information, use the qualifier PWK for data, followed by the appropriate
Report Type Code, the appropriate Transmission Type Code, then the Attachment Control Number. Do not
enter spaces between qualifiers and data. The NUCC defines the following qualifiers, since they are the same
as those used in the electronic 837 Professional 4010A1:
REPORT TYPE CODE
77
Support Data for Verification (REFERRAL - Use this code to indicate a completed referral form.)
AS
Admission Summary
B2
Prescription
B3
Physician Order
B4
Referral Form
CT
Certification
DA
Dental Models
DG
Diagnostic Report
DS
Discharge Summary
EB
Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
MT
Models
NN
Nursing Notes
OB
Operative Note
OZ
Support Data for Claim
PN
Physical Therapy Notes
PO
Prosthetics or Orthotic Certification
PZ
Physical Therapy Certification
RB
Radiology Films
RR
Radiology Reports
RT
Report of Tests and Analysis Report
TRANSMISSION TYPE CODE
AA
Available on Request at Provider Site
BM
By Mail
EL
Electronically Only (Use to indicate that attachment is being transmitted electronically)
EM
E-Mail
FX
By Fax
Example: PWK77FX12363545465
Field Specification: This field allows for the entry of 83 characters.
Example: None
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Item Number 20
Title: Outside Lab? $Charges
Instructions: Complete this field when billing for purchased services. Enter an X in "YES" if the reported
service(s) was performed by an entity other than the billing provider. If "YES", enter the purchased price
under charges. A "YES" mark indicates that an entity other than the entity billing for the service performed
the purchased services. A "NO" mark indicates that no purchased services are included on the claim. When
"YES" is annotated, Item Number 32 must be completed. When billing for multiple purchased services, each
service should be submitted on a separate claim form. Only one box can be marked.
When entering the charge amount, enter the amount in the field to the left of the vertical line. Enter the
number right justified to the left of the vertical line. Do not use commas or a decimal point when reporting
amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Use 00 for the cents if
the amount is a whole number. Leave the right-hand field blank.
Description: Outside lab? $Charges indicates that services have been rendered by an independent provider as
indicated in Item Number 32 and the related costs.
Field Specification: This field allows for the entry of the following: 1 character in either box in the Outside
Lab area and 8 characters to the left of the vertical line in the $Charges area.
Example:
x
112500
x
112575
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Item Number 21
Title: Diagnosis or Nature of Illness or Injury (relate items 1, 2, 3, or 4 to 24E by line)
Instructions: Enter the patient’s diagnosis/condition. List no more than four ICD-9-CM diagnosis codes.
Relate lines 1, 2, 3, 4 to the lines of service in 24E by line number. Use the highest level of specificity.
Do not provide narrative description in this field.
When entering the number, include a space (accommodated by the period) between the two sets of
numbers. If entering a code with more than 3 beginning digits (e.g., E codes), enter the fourth digit
above the period.
Description: The diagnosis or nature of illness or injury refers to the sign, symptom, complaint, or
condition of the patient relating to the service(s) on the claim.
Field Specification: This field allows for the entry of 3 characters prior to the period, 1 character above
the period, and 4 characters after the period in each of the four line areas.
Example:
998 59
V18 0
780 6
E878 8
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Item Number 22
Title: Medicaid Resubmission and/or Original Reference Number
Instructions: List the original reference number for resubmitted claims. Please refer to the most current
instructions from the applicable public or private payer regarding the use of this field (e.g., code).
When resubmitting a claim, enter the appropriate bill frequency code left justified in the left-hand side of the field.
7 – Replacement of prior claim
8 – Void/cancel of prior claim
This Item Number is not intended for use for original claim submissions.
Description: Medicaid resubmission means the code and original reference number assigned by the
destination payer or receiver to indicate a previously submitted claim or encounter.
Field Specification: This field allows for the entry of 11 characters in the Code area and 18 characters in
the Original Ref. No. area.
Example:
123
ABC1234567890
Item Number 23
Title: Prior Authorization Number
Instructions: Enter any of the following: prior authorization number or referral number, as assigned by the
payer for the current service, or the Clinical Laboratory Improvement Amendments (CLIA) number or the
mammography pre-certification number.
Do not enter hyphens or spaces within the number.
For Workers Compensation: Required when a prior authorization, referral, concurrent review, or voluntary
certification was received.
Description: The prior authorization number refers to the payer assigned number authorizing the service(s).
Field Specification: This field allows for the entry of 29 characters.
Example:
1234567890A
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Section 24
Instructions: Supplemental information can only be entered with a corresponding, completed service line.
The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI
and another/proprietary identifier during the NPI transition and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the
location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service.
The supplemental information is to be placed in the shaded section of 24A through 24G as defined in each
Item Number. Providers must verify requirements for this supplemental information with the payer.
See page 43 for further instructions and examples of how to enter supplemental information.
Field Specifications: The shaded area of lines 1 through 6 allow for the entry of 61 characters from the
beginning of 24A to the end of 24G.
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Item Number 24A
Title: Date(s) of Service [lines 1–6]
Instructions: Enter date(s) of service, from and to. If one date of service only, enter that date under "From."
Leave "To" blank or re-enter "From" date. If grouping services, the place of service, procedure code, charges,
and individual provider for each line must be identical for that service line. Grouping is allowed only for
services on consecutive days. The number of days must correspond to the number of units in 24G.
When required by payers to provide additional anesthesia services information (e.g., begin and end times),
narrative description of an unspecified code, NDC, VP – HIBCC codes, OZ – GTIN codes, contract rate, or
tooth numbers and areas of the oral cavity enter the applicable qualifier and number/code/information starting with the first space in the shaded line of this field. Do not enter a space, hyphen, or other separator
between the qualifier and the number/code/ information. The information may extend to 24G. Further
instructions on entering supplemental information with qualifiers, including examples, are on page 43.
Description: Date(s) of service indicate the actual month, day, and year the service(s) was provided.
Grouping services refers to a charge for a series of identical services without listing each date of service.
Field Specification: This field allows for the entry of the following in each of the unshaded date fields:
2 characters under MM, 2 characters under DD, and 2 characters under YY.
Example:
09 30 05 09 30 05
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Item Number 24B
Title: Place of Service [lines 1–6]
Instructions: In 24B, enter the appropriate two-digit code from the Place of Service Code list for
each item used or service performed. The Place of Service Codes are available at:
www.cms.hhs.gov/MedHCPCSGenInfo/Downloads/Place_of_Service.pdf.
Description: The Place of Service Code identifies the location where the service was rendered.
Field Specification: This field allows for the entry of 2 characters in the unshaded area.
Example:
11
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Item Number 24C
Title: EMG [lines 1–6]
This Item Number was originally titled "Type of Service" and "Type of Service" is no longer used so it has been
eliminated.
Instructions: Check with trading partner to determine if this element (emergency indicator) is necessary. If
required, enter Y for "YES" or leave blank if "NO" in the bottom, unshaded area of the field. The definition of
emergency would be either defined by federal or state regulations or programs, payer contracts, or as defined
in the electronic 837 Professional 4010A1 implementation guide.
Field Specification: This field allows for the entry of 2 characters in the unshaded area.
Example:
Y
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Item Number 24D
Title: Procedures, Services, or Supplies [lines 1–6]
Instructions: Enter the CPT or HCPCS code(s) and modifier(s) (if applicable) from the appropriate code
set in effect on the date of service. This field accommodates the entry of up to four two-digit modifiers. The
specific procedure code(s) must be shown without a narrative description.
Description: The procedures, services or supplies refer to a listing of identifying codes for reporting medical
services and procedures.
Field Specification: This field allows for the entry of the following: 6 characters in the unshaded area of the
CPT/HCPCS field and four sets of 2 characters in the Modifier area.
Example:
99241
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36
Item Number 24E
Title: Diagnosis Pointer [lines 1–6]
Instructions: In 24E, enter the diagnosis code reference number (pointer) as shown in Item Number 21 to
relate the date of service and the procedures performed to the primary diagnosis. When multiple diagnoses
are related to one service, the reference number for the primary diagnosis should be listed first, other applicable diagnosis reference numbers should follow. The reference number(s) should be a 1, or a 2, or a 3, or a
4; or multiple numbers as explained. (ICD-9-CM diagnosis codes must be entered in Item Number 21 only. Do
not enter them in 24E.)
Enter numbers left justified in the field. Do not use commas between the numbers.
Description: The diagnosis pointer refers to the line number from Item Number 21 that relates to the reason
the service(s) was performed.
Field Specification: This field allows for the entry of 4 characters in the unshaded area.
Example:
1234
324
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Item Number 24F
Title: $ Charges [lines 1–6]
Instructions: Enter the charge for each listed service.
Enter number right justified in the dollar area of the field. Do not use commas when reporting dollar
amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents
area if the amount is a whole number.
Description: $ charges refers to the total billed amount for each service line.
Field Specification: This field allows for the entry of 6 characters to the left of the vertical line and
2 characters to the right of the vertical line in the unshaded area.
Example:
50 00
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Item Number 24G
Title: Days or Units [lines 1–6]
Instructions: Enter the number of days or units. This field is most commonly used for multiple visits, units of
supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must
be entered.
Enter numbers right justified in the field. No leading zeros are required. If reporting a fraction of a unit, use
the decimal point.
Description: Days or units refers to the number of days corresponding to the dates entered in 24A or units as
defined in CPT or HCPCS coding manual(s).
Field Specification: This field allows for the entry of 3 characters in the unshaded area.
Examples:
1
1.5
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Item Number 24H
Title: EPSDT/Family Plan [lines 1–6]
Instructions: For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response
in the shaded portion of the field as follows:
If there is no requirement (e.g., state requirement) to report a reason code for EPDST, enter Y for “YES” or
N for “NO” only.
If there is a requirement to report a reason code for EPDST, enter the appropriate reason code as noted
below. (A Y or N response is not entered with the code.) The two character code is right justified in the
shaded area of the field.
The following codes for EPSDT are used in the electronic 837 Professional 4010A1:
AV
S2
ST
NU
Available – Not Used (Patient refused referral.)
Under Treatment (Patient is currently under treatment for referred diagnostic or corrective health
problem.)
New Service Requested (Referral to another provider for diagnostic or corrective treatment/
scheduled for another appointment with screening provider for diagnostic or corrective treatment
for at least one health problem identified during an initial or periodic screening service, not
including dental referrals.)
Not Used (Used when no EPSDT patient referral was given.)
If the service is Family Planning, enter Y (“YES”) or N (“NO”) in the bottom, unshaded area of the field.
Description: The EPSDT/Family Plan identifies certain services that may be covered under some state plans.
Field Specification: This field allows for the entry of 1 character in the unshaded area and 2 characters in
the shaded area.
Examples:
Y
Y
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40
Item Number 24I
Title: ID Qualifier [lines 1–6]
This field was originally labeled "EMG". However, "EMG" is now located in 24C.
Instructions: Enter in the shaded area of 24I the qualifier identifying if the number is a non-NPI. The
Other ID# of the rendering provider is reported in 24J in the shaded area. The NUCC defines the following
qualifiers, since they are the same as those used in the electronic 837 Professional 4010A1:
0B State License Number
1B Blue Shield Provider Number
1C Medicare Provider Number
1D Medicaid Provider Number
1G Provider UPIN Number
1H CHAMPUS Identification Number
EI Employer’s Identification Number
G2 Provider Commercial Number
LU Location Number
N5 Provider Plan Network Identification Number
SY Social Security Number (The social security number may not be used for Medicare.)
X5 State Industrial Accident Provider Number
ZZ Provider Taxonomy
The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identifiers are assigned to the provider either by a specific payer or by a third party in order to uniquely identify the
provider. The taxonomy code is designated by the provider in order to identify his/her provider type, classification, and/or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.
The Rendering Provider is the person or company (laboratory or other facility) who rendered or supervised the care.
In the case where a substitute provider (locum tenens) was used, enter that provider’s information here. Report the
Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b.
Description: If the provider does not have an NPI number, enter the appropriate qualifier and identifying
number in the shaded area. There will always be providers who do not have an NPI and will need to report
non-NPI identifiers on their claim forms. The qualifiers will indicate the non-NPI number being reported.
Field Specification: This field allows for the entry of a 2 character qualifier in the shaded area.
Example:
1B
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Item Number 24J
Title: Rendering Provider ID # [lines 1–6]
Instructions: The individual rendering the service is reported in 24J. The original fields for 24J and 24K have
been combined and re-numbered as 24J. Enter the non-NPI ID number in the shaded area of the field. Enter
the NPI number in the unshaded area of the field.
The Rendering Provider is the person or company (laboratory or other facility) who rendered or supervised
the care. In the case where a substitute provider (locum tenens) was used, enter that provider’s information
here. Report the Identification Number in Items 24I and 24J only when different from data recorded in items
33a and 33b.
Enter numbers left justified in the field.
Description: The non-NPI ID number of the rendering provider refers to the unique identifier of the
professional or to the provider designated taxonomy code.
Field Specification: This field allows for the entry of 11 characters in the shaded area and entry of a 10 digit
NPI number of the unshaded area.
Example:
Z5678901234
9876543210
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Instructions and Examples of Supplemental Information in Item Number 24
The following are types of supplemental information that can be entered in the shaded lines of
Item Number 24:
• Anesthesia duration in hours and/or minutes with start and end times
• Narrative description of unspecified codes
• National Drug Codes (NDC) for drugs
• Vendor Product Number – Health Industry Business Communications Council (HIBCC)
• Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN), formerly
Universal Product Code (UPC) for products
• Contract rate
• Tooth numbers and areas of the oral cavity
The following qualifiers are to be used when reporting these services.
7
ZZ
N4
VP
Anesthesia information
Narrative description of unspecified code
National Drug Codes (NDC)
Vendor Product Number Health Industry Business Communications Council (HIBCC)
Labeling Standard
OZ Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN)
CTR Contract rate
JP Universal/National Tooth Designation System
JO ANSI/ADA/ISO Specification No. 3950-1984 Dentistry Designation System for Tooth and Areas of the
Oral Cavity
If required to report other supplemental information not listed above, follow payer instructions for the use of
a qualifier for the information being reported. When reporting a service that does not have a qualifier, enter
two blank spaces before entering the information
To enter supplemental information, begin at 24A by entering the qualifier and then the information. Do not
enter a space between the qualifier and the number/code/information. Do not enter hyphens or spaces within
the number/code.
More than one supplemental item can be reported in the shaded lines of Item Number 24. Enter the first
qualifier and number/code/information at 24A. After the first item, enter three blank spaces and then the
next qualifier and number/code/information.
When reporting dollar amounts in the shaded area, always enter dollar amount, a decimal point, and cents.
Use 00 for the cents if the amount is a whole number. Do not use commas. Do not enter dollar signs.
Examples:
1000.00
123.45
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Additional Information for Reporting NDC
When entering supplemental information for NDC, add in the following order: qualifier, NDC code, one space,
unit/basis of measurement qualifier, quantity. The number of digits for the quantity is limited to eight digits
before the decimal and three digits after the decimal. If entering a whole number, do not use a decimal. Do
not use commas.
Examples:
1234.56
2
99999999.999
When a dollar amount is being reported, enter the following after the quantity: one space, dollar amount. Do
not enter a dollar sign.
The following qualifiers are to be used when reporting NDC unit/basis of measurement:
F2
GR
International Unit
Gram
ML
UN
Milliliter
Unit
Additional Information for Reporting Tooth Numbers and Areas of the Oral Cavity
When reporting tooth numbers, add in the following order: qualifier, tooth number, e.g., JP16. When reporting
an area of the oral cavity, enter in the following order: qualifier, area of oral cavity code, e.g., JO10.
When reporting multiple tooth numbers for one procedure, add in the following order: qualifier, tooth number,
blank space, tooth number, blank space, tooth number, etc., e.g., JP1 16 17 32.
When reporting multiple tooth numbers for one procedure, the number of units reported in 24G is the number of teeth involved in the procedure.
When reporting multiple areas of the oral cavity for one procedure, add in the following order: qualifier, oral
cavity code, blank space, oral cavity code, etc., e.g., JO10 20.
When reporting multiple areas of the oral cavity for one procedure, the number of units reported in 24G is the
number of areas of the oral cavity involved in the procedure.
The following are the codes for tooth numbers, reported with the JP qualifier:
1 – 32
Permanent dentition
51 – 82
Permanent supernumerary dentition
A–T
Primary dentition
AS – TS
Primary supernumerary dentition
The following are the codes for areas of the oral cavity, reported with the JO qualifier:
00
Entire oral cavity
01
Maxillary arch
02
Mandibular arch
10
Upper right quadrant
20
Upper left quadrant
30
Lower left quadrant
40
Lower right quadrant
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For further information on these codes, refer to the Current Dental Terminology (CDT) Manual available
from the American Dental Association.
Please note: The following examples are of how to enter different types of supplemental information in 24.
These examples demonstrate how the data are to be entered into the fields and are not meant to provide
direction on how to code for certain services.
Anesthesia Services, when payment based on 15 minute units:
7Begin 1245 End 1415 Time 90 minutes
10 01 05 10 01 05 22
00770
P2
134
875 00 6
N 1B 12345678901
N
0123456789
875 00 90
N 1B 12345678901
N
0123456789
165 00 1
N
N
Anesthesia Services, when payment based on minutes as units:
7Begin 1245 End 1415
10 01 05 10 01 05 22
00770
P2
134
Unspecified Code:
ZZKaye Walker
10 01 05 10 01
1B 12345678901
0123456789
05 12
E1399
12
05 11
J0400
1
250 00
N 1B 12345678901
40 N
0123456789
N44950267230 UN1 50.00
10 01 05 10 01 05 11
J7603
1
50 00
N 1B 12345678901
2.5 N
0123456789
NDC Code:
N45914801665 UN1
10 01 05 10 01
Vendor Product Number Health Industry Business Communications Council (HIBCC):
VPA122BIC5D6E7G
10 01 05 10 01
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A6410
13
45
15 00
1
1
N 1B 12345678901
N
0123456789
Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN):
OZ00301134678906
10 01 05 10 01
2
2
N 1B 12345678901
N
0123456789
05 12
A6410
13
500 00
05 11
D7240
1
500 00
N 1B 12345678901
1 N
0123456789
05 11
D7240
1
500 00
N 1B 12345678901
4 N
0123456789
05 11
41820
1
500 00
N 1B 12345678901
1 N
0123456789
D7310
1
500 00
N 1B 12345678901
2 N
0123456789
Tooth Number
JP1
10 01 05 10 01
Multiple Tooth Numbers
JP1 16 17 32
10 01 05 10 01
Area of Oral Cavity
JO10
10 01 05 10 01
Multiple Areas of Oral Cavity
JO10 20
10 01 05 10 01
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Item Number 25
Title: Federal Tax ID Number
Instructions: Enter the Federal Tax ID Number (employer identification number or Social Security number)
of the Billing Provider identified in Item Number 33. This is the tax ID number intended to be used for 1099
reporting purposes. Enter an X in the appropriate box to indicate which number is being reported. Only one
box can be marked.
Do not enter hyphens with numbers. Enter numbers left justified in the field.
Description: The federal tax ID number refers to the unique identifier assigned by a federal or state agency.
Field Specification: This field allows for the entry of 15 characters for the Federal Tax ID Number and 1
character in either box.
Example:
x
Item Number 26
Title: Patient’s Account No.
Instructions: Enter the patient’s account number assigned by the provider of service’s or supplier’s accounting system.
Do not enter hyphens with numbers. Enter numbers left justified in the field.
Description: The patient’s account number refers to the identifier assigned by the provider.
Field Specification: This field allows for the entry of 14 characters.
Example:
12341234
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Item Number 27
Title: Accept Assignment?
Instructions: Enter an X in the correct box. Only one box can be marked.
Description: The accept assignment indicates that the provider agrees to accept assignment under the terms
of the Medicare Program.
Field Specification: This field allows for the entry of 1 character in either box.
Example:
x
Item Number 28
Title: Total Charge
Instructions: Enter total charges for the services (i.e., total of all charges in 24F).
Enter number right justified in the dollar area of the field. Do not use commas when reporting dollar
amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents
area if the amount is a whole number.
Description: The total charge indicates the total billed amount for all services entered in 24F (lines 1–6).
Field Specification: This field allows for the entry of 7 characters to the left of the vertical line and 2 characters to the right of the vertical line.
Example:
1125 00
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Item Number 29
Title: Amount Paid
Instructions: Enter total amount the patient or other payers paid on the covered services only.
Enter number right justified in the dollar area of the field. Do not use commas when reporting dollar
amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents
area if the amount is a whole number.
Description: The amount paid refers to the payment received from the patient or other payers.
Field Specification: This field allows for the entry of 6 characters to the left of the vertical line and
2 characters to the right of the vertical line.
Example:
10 00
Item Number 30
Title: Balance Due
Instructions: Balance Due does not exist in the electronic 837 Professional 4010A1.
Enter total amount due.
Enter number right justified in the dollar area of the field. Do not use commas when reporting dollar
amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents
area if the amount is a whole number.
Field Specification: This field allows for the entry of 6 characters to the left of the vertical line and
2 characters to the right of the vertical line.
Example:
1115 00
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Item Number 31
Title: Signature of Physician or Supplier Including Degrees or Credentials
Instructions: Signature of Physician or Supplier Including Degrees or Credential and date does not exist in
the electronic 837 Professional 4010A1.
Enter the legal signature of the practitioner or supplier, signature of the practitioner or supplier representative, “Signature on File,” or “SOF.” Enter either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD |
CCYY), or alphanumeric date (e.g., January 1, 2003) the form was signed.
Description: The signature of the physician or supplier including degrees or credentials refers to the authorized or accountable person and the degree, credentials, or title.
Field Specification: Use the space available to enter signature and date.
Example:
Joe Smith MD
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Item Number 32, 32a, and 32b
Title 32: Service Facility Location Information
Instructions: Enter the name, address, city, state, and zip code of the location where the services were
rendered. Providers of service (namely physicians) must identify the supplier’s name, address, zip code, and
NPI number when billing for purchased diagnostic tests. When more than one supplier is used, a separate
1500 Claim Form should be used to bill for each supplier.
Enter the name and address information in the following format:
1st Line – Name
2nd Line – Address
3rd Line – City, State and ZIP Code
Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of
123 N. Main Street, #101). Enter a space between town name and state code; do not include a comma.
When entering a 9 digit ZIP code, include the hyphen.
If a foreign address, contact payer for specific reporting instructions.
Description: The name and address of facility where services were rendered identifies the site where
service(s) were provided.
Field Specification: This field allows for the entry of three lines of 26 characters each in the Service Facility
Location Information area.
Title 32a: NPI#
Instructions: Enter the NPI number of the service facility location in 32a.
Description: The NPI number refers to the HIPAA National Provider Identifier number.
Field Specification: This field allows for the entry of 10 characters.
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Title 32b: Other ID#
Instructions: Enter the two digit qualifier identifying the non-NPI number followed by the ID number. Do not
enter a space, hyphen, or other separator between the qualifier and number. The NUCC defines the following
qualifiers, since they are the same as those used in the electronic 837 Professional 4010A1:
0B
1A
1B
1C
1D
1G
1H
G2
LU
N5
TJ
X4
X5
ZZ
State License Number
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Federal Taxpayer’s Identification Number
Clinical Laboratory Improvement Amendment Number
State Industrial Accident Provider Number
Provider Taxonomy
The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identifiers are assigned to the provider either by a specific payer or by a third party in order to uniquely identify the
provider. The taxonomy code is designated by the provider in order to identify his/her provider type, classification, and/or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.
Description: The non-NPI number of the service facility refers to the unique identifier of the professional or
to the provider designated taxonomy code.
Field Specification: This field allows for the entry of 14 characters in 32b.
Example:
Physician Practice Inc
1234 Healthcare Street
Anytown IL 60610-1234
9876543210
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Item Number 33, 33a, and 33b
Title 33: Billing Provider Info & Ph #
Instructions: Enter the provider’s or supplier’s billing name, address, zip code, and phone number. The phone
number is to be entered in the area to the right of the field title. Enter the name and address information in
the following format:
1st Line – Name
2nd Line – Address
3rd Line – City, State and ZIP Code
Item 33 identifies the provider that is requesting to be paid for the services rendered and should always be
completed.
Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of
123 N. Main Street, #101). Enter a space between town name and state code; do not include a comma.
When entering a 9 digit ZIP code, include the hyphen. Do not use a hyphen or space as a separator within
the telephone number.
If a foreign address, contact payer for specific reporting instructions.
Description: The billing provider’s or supplier’s billing name, address, zip code, and phone number refers to
the billing office location and telephone number of the provider or supplier.
Field Specification: This field allows for the entry of the following: 3 characters for area code, 9 characters
for phone number, and three lines of 29 characters each in the Billing Provider Info area.
Title 33a: NPI#
Instructions: Enter the NPI number of the billing provider in 33a.
Description: The NPI number refers to the HIPAA National Provider Identifier number.
Field Specification: This field allows for the entry of 10 characters.
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Title 33b: Other ID#
Instructions: Enter the two digit qualifier identifying the non-NPI number followed by the ID number. Do not
enter a space, hyphen, or other separator between the qualifier and number. The NUCC defines the following
qualifiers, since they are the same as those used in the electronic 837 Professional 4010A1:
0B
1A
1B
1C
1D
1G
1H
1J
B3
BQ
FH
G2
G5
LU
U3
X5
ZZ
State License Number
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Facility ID Number
Preferred Provider Organization Number
Health Maintenance Organization Code Number
Clinic Number
Provider Commercial Number
Provider Site Number
Location Number
Unique Supplier Identification Number (USIN)
State Industrial Accident Provider Number
Provider Taxonomy
The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identifiers are assigned to the provider either by a specific payer or by a third party in order to uniquely identify the
provider. The taxonomy code is designated by the provider in order to identify his/her provider type, classification, and/or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.
Description: The non-NPI number of the billing provider refers to the unique identifier of the provider or to
the provider designated taxonomy code.
Field Specification: This field allows for the entry of 17 characters in 33b.
Example:
312
5552222
Physician Practice Inc
1234 Healthcare Street
Anytown IL 60610-1234
9876543210
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APPENDIX A: ABBREVIATIONS
AMA – American Medical Association
BLK Lung – Black Lung
CCYY – Year, indicates entry of four digits for the century (CC) and year (YY)
CHAMPUS – Civilian Health and Medical Program of the Uniformed Services
CHAMPVA – Civilian Health and Medical Program of the Department of Veterans Affairs
CLIA – Clinical Laboratory Improvement Amendments
CMS – Centers for Medicare & Medicaid Services, formerly HCFA
COB – Coordination of Benefits
CPT® – Current Procedural Terminology, 4th Edition
DD – Day, indicates entry of two digits for the day
DME – Durable Medical Equipment
EIN – Employer Identification Number
EMG – Emergency
EPSDT – Early & Periodic Screening, Diagnosis, and Treatment
F – Female
FECA – Federal Employees’ Compensation Act
GTIN – Global Trade Item Number
HCFA – Health Care Financing Administration, currently CMS
HCPCS – HCFA Common Procedural Coding System
HIBCC – Health Industry Business Communications Council
HIPAA – Health Insurance Portability and Accountability Act of 1996
HMO – Health Maintenance Organization
ICD-9-CM – International Classification of Disease - Revision 9 - Clinical Modification
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I.D. or ID. – Identification
ID # or ID. # – Identification Number
INFO – Information
LMP – Last Menstrual Period
M – Male
MM – Month, indicates entry of two digits for the month
NDC – National Drug Codes
No. – Number
NUCC – National Uniform Claim Committee
NUCC-DS – National Uniform Claim Committee Data Set
NPI – National Provider Identifier
OMB – Office of Management and Budget
OZ – Product number Health Care Uniform Code Council
PH # – Phone Number
QUAL. – Qualifier
REF. – Reference
SOF – Signature on File
SSN – Social Security Number
UPC – Universal Product Code
UPIN – Unique Physician Identification Number
USIN – Unique Supplier Identification Number
VP – Vendor Product Number
YY – Year, indicates entry of two digits for the year; may also be noted as CCYY, which allows for entry of four
digits for the century (CC) and year (YY)
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APPENDIX B: GUIDELINES FOR MODIFYING THE 1500 (08/05) CLAIM FORM
The following are the National Uniform Claim Committee’s (NUCC) recommended guidelines for making
modifications to the 1500 (08/05) Claim Form.
Printer-specific/Supplier-specific Information
Any printer-specific/supplier-specific information (e.g., logo, reorder number, phone number) that is preprinted on the form must be placed in a manner in which it will not interfere with the data content of the
form. Data content includes the carrier information at the top of the page and any other pre-printed text in
the margins. (See the instructions for the location of the carrier information within the carrier block of the
form.)
Tracking Information Added By Clearinghouses, Payers, or Other Processors
Any tracking information (e.g., time stamp, tracking number) that is added by clearinghouses, payers, or
other claims processors must be placed in a manner in which it will not interfere with the data content of the
form. Data content includes the carrier information at the top of the page. (See the instructions for the location of the carrier information within the carrier block of the form.)
Barcodes
Any barcodes added to the form, either pre-printed or during processing, must be placed in a manner in
which it will not interfere with the data content of the form. Data content includes the carrier information at
the top of the page. (See the instructions for the location of the carrier information within the carrier block
of the form.)
Additional Data Elements
The NUCC strongly discourages required or optional reporting of any data elements in addition to the data
content fields on the form.
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APPENDIX C: MAINTENANCE OF THE 1500 REFERENCE INSTRUCTION MANUAL
Version Releases
Updated versions of the 1500 Claim Form Reference Instruction Manual will be released yearly on July 1.
Any changes, clarifications, or errata will be listed on the NUCC website, at www.nucc.org under the 1500
Claim Form tab, with the issue and effective date of the change.
Maintenance Process
1. Requests for clarifications or changes to the 1500 Instruction Manual should be submitted by completing
the 1500 Claim Form Instructions Change Request Form (see Attachment 1 to Appendix C). The request/
form can then be emailed to Nancy Spector, NUCC Chair, at [email protected]
2. The Data/1500 Subcommittee will review the requests for changes or clarifications to the 1500 Instruction
Manual. The subcommittee’s review may include any of the following:
• coordinating the request with requirements outlined in the 837 Professional implementation guide
adopted under HIPAA,
• gaining a wider understanding of the industry’s need related to the request,
• gathering additional data, when necessary, on the overall impact of the request, and/or
• balancing the needs of the requester versus the industry
3. The Data/1500 Subcommittee will develop a recommended response and, when appropriate, any
corresponding changes to the Instruction Manual.
4. The NUCC will review the request and recommendation made by the Data/1500 Subcommittee.
5. The NUCC will make the final decision in response to the request.
6. The requester will be notified of the NUCC’s final decision.
7. Final decisions may be appealed by the requester resubmitting the request along with additional
supporting information.
8. If changes and/or clarifications are made to the instructions as a result of the final decision, they will be
included on the NUCC’s website under the 1500 Claim Form tab with the listing of changes, clarifications,
and/or errata.
9. All changes, clarifications, and edits from the previous release will be incorporated into the Instruction
Manual for the yearly release on July 1.
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Attachment 1 to Appendix C – 1500 Claim Form Instructions Change Request Form
1500 Claim Form Instruction Change Request
(Provide requested information / Mark applicable box)
Date:
1. Requester Information
Individual’s Name:
Address (Line 1):
Address (Line 2):
City:
State:
Zip Code
Telephone:
Fax:
E-mail:
2. Does this request and information provided represent the official position of a particular health care
organization or a third-party payer/administrator?
Yes:
If Yes, please provide
Organization / Entity Name:
No:
3. Is this request for an instruction revision or deletion?
Revision:
Deletion:
Go to Question 4
4. Specify current 1500 claim
Item #
form Item # to be REVISED.
Go to Question 8
Page
5. Description of proposed revision
Check here ___ if continued on a separate sheet
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6. Reason for proposed revision, including reasons why the existing instruction is inadequate.
Check here ___ if continued on a separate sheet
7. Proposed revised instruction (text additions underlined in blue; text deletions stricken-through in red).
Check here ___ if continued on a separate sheet
8. Specify current 1500 claim
form Item # to be DELETED.
Item #
Page
9. Reason for Proposed deletion, including reasons why the existing instruction is no longer appropriate.
Check here ___ if continued on a separate sheet
Questions 10 through 12 apply to requests for revision or deletion.
10. Is there supporting documentation or literature that you wish to submit?
Yes:
No:
11. If Yes, please note how material will be submitted.
“Fax”:
Surface Mail:
E-Mail:
12. Additional Comments:
Check here ___ if continued on a separate sheet
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