Claim Form Manual V7 0 7 11

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National Uniform Claim Committee

1500 Health Insurance Claim Form

Reference Instruction Manual

For Form Version 08/05

July 2011

Version 7.0 07/11

NUCCTM

National Uniform Claim Committee

Version 7.0

07/11

Disclaimer and Notices

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

FARS/DFARS restrictions apply.

The 1500 Health Insurance Claim Form (1500 Claim Form) is in the public domain.

The NUCC has developed this general instructions document for completing the 1500 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 instruc-

tions 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 expressed 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

Scope of Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .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

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

Appendix A: Provider Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

Appendix B: Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

Appendix C: Guidelines for Modifying the 1500 (08/05) Claim Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Appendix D: Maintenance of the 1500 Reference Instruction Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

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1500 CLAIM FORM INSTRUCTIONS: BACKGROUND INFORMATION

The 1500 Health Insurance Claim Form answers the needs of many health care payers. It is the basic paper

claim form prescribed by many payers 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.

There was no standardized form, however, 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.

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. Although many providers now

submit electronic claims, many of their software/hardware systems depend on the existing 1500 Claim Form

in its current image.

SCOPE OF INSTRUCTIONS

This NUCC Reference Instruction Manual provides specific instructions on how to complete the 1500 Claim

Form. Instructions and information provided align with the Health Care Claim: Professional (837),

004010X222A1 Implementation Guide (4010A1); Health Care Claim: Professional (837), 005010X222 Technical

Report Type 3 (5010); and 005010X222A1 Technical Report Type 3 (5010A1). 5010 and 5010A1 are collectively

referred to as “5010A1” in this manual.

The 5010A1 instructions are effective as of January 1, 2012.

The 1500 Claim Form instructions were initially approved by the NUCC in November, 2005. The NUCC contin-

ues 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 instruc-

tions have and will continue to evolve. Updated versions of this instruction manual are released each July.

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. Refer to specific

instructions issued by your payer, clearinghouse, and/or vendor for further clarification of reporting require-

ments.

The 1500 Claim Form may also be used to report patient encounter data to federal, state, and/or other public

health agencies. Refer to instructions issued by these agencies for further clarification of reporting require-

ments.

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OVERALL INSTRUCTIONS

Each Item Number includes the title, instructions, description, field specifications, and example. The exam-

ples 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 Descriptor Type Bytes Columns

4 Payer Name A/N 41 38-78

5 Payer Address 1 A/N 41 38-78

6 Payer Address 2 A/N 41 38-78

7 Payer City State and ZIP A/N 41 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 Descriptor Type Bytes Columns

4 Payer Name A/N 41 38-78

5 Payer Address A/N 41 38-78

6 Leave blank

7 Payer City State and ZIP A/N 41 38-78

Do not use punctuation (i.e., commas, periods) or other symbols, 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 (generally done by clearinghouses when converting

4010A1 or 5010A1 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:

Three line address:

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ABC Insurance Company

Suite 600

567 Insurance Lane

Big City IL 60605

Page 01 of 02

ABC Insurance Company

567 Insurance Lane

Big City IL 60605

Page 01 of 02

ITEMS 1–13: PATIENT AND INSURED INFORMATION

5010A1 Instruction: If the patient can be identified by a unique Member Identification Number,

the patient is considered to be the “insured”. The patient is reported as the insured in the insured

data fields and not in the patient fields.

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:

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. If the patient has a unique Member Identification Number assigned by the payer, then enter

that number in this field.

For Workers Compensation Claims: Enter Employee ID

For Other Property & Casualty Claims: Enter the Federal Tax ID or Social Security number of the insured

person or entity.

Description: The “Insured’s ID Number” is the identification number of the insured. This information identi-

fies the insured to the payer.

Field Specification: This field allows for entry of 29 characters.

Example:

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x0123456789

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.

If the patient’s name is the same as the insured’s name (i.e., the patient is the insured), then it is not neces-

sary to report the patient’s 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:

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, 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:

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Doe Jr, John, J

01 01 1987 x

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 Claims: Enter the name of the employer.

For Other Property & Casualty Claims: Enter the name of the insured person or entity.

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:

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Doe, John, J

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.

Do not use punctuation (i.e., commas, periods) or other symbols 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.

If reporting a foreign address, contact payer for specific reporting instructions.

If the patient’s address is the same as the insured’s address, then it is not necessary to report the patient’s

address.

“Patient’s Telephone” does not exist in 4010A1 or 5010A1. The NUCC recommends that the phone number not

be reported.

For Workers’ Compensation and Other Property and Casualty Claims: If required by a payer to report a

telephone number, do not use a hyphen or space as a separator within the telephone number.

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 charac-

ters for city, 3 characters for state, 12 characters for ZIP code, 3 characters for area code, and 10 characters

for phone number.

Example:

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123 Main Street

Anytown IL

60610 312 5551212

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.

5010A1: If the patient is a dependent, but has a unique Member Identification Number and the

payer requires the identification number be reported on the claim, then report “Self”, since the

patient is reported as the insured.

Field Specification: This field allows for entry of 1 character in any box within the field.

Example:

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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.

Do not use punctuation (i.e., commas, periods) or other symbols, 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.

If reporting a foreign address, contact payer for specific reporting instructions.

“Insured’s Telephone” does not exist in 4010A1 or 5010A1. The NUCC recommends that the phone number not

be reported.

For Workers Compensation Claims: Enter the address of the employer.

For Other Property & Casualty Claims: Enter the address of the insured noted in Item Number 4.

For Workers’ Compensation and Other Property and Casualty Claims: If required by a payer to report a

telephone number, do not use a hyphen or space as a separator within the telephone number.

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 char-

acters for city, 4 characters for state, 12 characters for ZIP code, 3 characters for area code, and 10 charac-

ters for phone number.

Example:

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123 Main Street

Anytown IL

60610 312 5551212

Item Number 8

Title: Patient Status

Instructions: “Patient Status” does not exist in 4010A1 or 5010A1. The NUCC recommends that this field not

be used.

If required by a payer to report, 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.

Field Specification: This field allows for entry of 1 character in any box within the field.

Example:

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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 addi-

tional 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:

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:

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Doe, Mary, A

x9876543210

Item Number 9b

Title: Other Insured’s Date of Birth, Sex

Instructions: “Other Insured’s Date of Birth, Sex” does not exist in 4010A1 or 5010A1. The NUCC recommends

that this field not be used.

If required by payer to report, 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, 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:

Item Number 9c

Title: Employer’s Name or School Name

Instructions: “Employer’s Name or School Name” does not exist in 4010A1 or 5010A1. The NUCC recommends

that this field not be used.

If required by a payer to report, 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:

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01 01 1960 x

Community Hospital

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:

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XYZ Insurance Company

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 auto-

mobile or other accident. Only one box on each line can be marked.

The state postal code where the accident occured must be reported, 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:

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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. The Condition Codes approved for use on the 1500 Claim Form are available at

www.nucc.org under Code Sets.

For Workers Compensation Claims: 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 and Other Property & Casualty Claims: Required if known. Enter Workers’

Compensation or Property & Casualty 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. For worker’s compensation claims the workers compensation

carrier’s alphanumeric identifier would be used. 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:

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A1234

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, 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:

Item Number 11b

Title: Employer’s Name or School Name

Instructions: “Employer’s Name or School Name” does not exist in 4010A1 or 5010A1. The NUCC recommends

that this field not be used.

If required by payer to report, 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:

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01 01 1958 x

Local Company

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:

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:

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ABC Insurance Company

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:

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:

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SOF

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:

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.

5010A1 Instruction: “If Patient Has Had Same or Similar Illness” does not exist in 5010A1. The

NUCC recommends that this field not be used.

If required by payer to report, 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:

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09 30 2005

09 25 2005

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” refers 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:

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(ies) on the claim.

Field Specification: This field allows for the entry of 26 characters.

Example:

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09 25 2005 10 28 2005

Jane A Smith MD

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 used in 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 identi-

fiers 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, classifica-

tion, and/or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.

5010A1 Instructions: The NUCC defines the following qualifiers used in 5010A1:

0B State License Number

1G Provider UPIN Number

G2 Provider Commercial Number

LU Location Number (This qualifier is used for Supervising Provider only.)

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.

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Field Specification: This field allows for the entry of a 10-digit NPI number

Example:

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G2 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” refers 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:

tem 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 4010A1 and 5010A1

09 25 2005 09 28 2005

4010A1 5010A1

0B State License Number 0B State License Number

1B Blue Shield Provider Number 1G Provider UPIN Number

1C Medicare Provider Number G2 Provider Commercial Number

1D Medicaid Provider Number

1G Provider UPIN Number

LU Location Number (This qualifier is used for

Supervising provider only

1H CHAMPUS Identification Number N5 Provider Plan Network Identification Number

EI Employer’s Identification Number

G2 Provider Commercial Number

SY Social Security Number (The social security number

may not be used for Medicare.)

X5 State Industrial Accident Provider Number

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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, classifi-

cation, and/or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.

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 4010A1 and 5010A1:

REPORT TYPE CODE

4010A1 5010A1

LU Location Number ZZ Provider Taxonomomy (The qualifier in the 5010A1

for Provider Taxonomy is PXC, but ZZ will remain the

qualifier for the 1500 Claim form.

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

4010A1 5010A1

77 Support Data for Verification (REFERRAL - Use

this code to indicate a completed referral form.)

03 Report Justifying Treatment Beyond Utilization

04 Drugs Administered

AS Admission Summary 05 Treatment Diagnosis

B2 Prescription 06 Initial Assessment

B3 Physician Order 07 Functional Goals

B4 Referral Form 08 Plan of Treatment

CT Certification 09 Progress Report

DA Dental Models 10 Continued Treatment

DG Diagnostic Report 11 Chemical Analysis

DS Discharge Summary 13 Certified Test Report

EB Explanation of Benefits (Coordination of Benefits

or Medicare Secondary Payor)

15 Justification for Admission

21 Recovery Plan

MT Models A3 Allergies/Sensitivities Document

NN Nursing Notes A4 Autopsy Report

OB Operative Note AM Ambulance Certification

OZ Support Data for Claim AS Admission Summary

PN Physical Therapy Notes B2 Prescription

PO Prosthetics or Orthotic Certification B3 Physician Order

PZ Physical Therapy Certification B4 Referral Form

RB Radiology Films BR Benchmark Testing Results

RR Radiology Reports

RT Report of Tests and Analysis Report

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BS Baseline

BT Blanket Test Results

CB Chiropractic Justification

CK Consent Form(s)

CT Certification

D2 Drug Profile Document

DA Dental Models

DB Durable Medical Equipment Prescription

DG Diagnostic Report

DJ Discharge Monitoring Report

DS Discharge Summary

EB Explanation of Benefits (Coordination of Benefits or

Medicare Secondary Payor)

HC Health Certificate

HR Health Clinic Reports

I5 Immunization Record

IR State School Immunization Records

LA Laboratory Results

M1 Medical Record Attachment

MT Models

NN Nursing Notes

OB Operative Note

OC Oxygen Content Averaging Report

OD Orders and Treatments Document

OE Objective Physical Examination (including vital signs)

Document

OX Oxygen Therapy Certification

OZ Support Data for Claim

P4 Pathology Report

P5 Patient Medical History Document

PE Parenteral or Enteral Certification

PN Physical Therapy Notes

PO Prosthetics or Orthotic Certification

PQ Paramedical Results

PY Physician’s Report

PPZ Physical Therapy Certification

RB Radiology Films

RR Radiology Reports

RT Report of Tests and Analysis Report

RX Renewable Oxygen Content Averaging Report

SG Symptoms Document

V5 Death Notification

XP Photographs

TRANSMISSION TYPE CODE

AA Available on Request at Provider Site

BM By Mail

Example: PWK03AA12363545465

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 by entering an X in “YES.” A “YES” mark

indicates that the reported service was provided by an entity other than the billing provider (for example,

services subject to Medicare’s anti-markup rule). A “NO” mark or blank indicates that no purchased services

are included on the claim.

If “Yes” is annotated, enter the purchase price under “$Charges” and complete Item Number 32. Each pur-

chased service must be reported on a separate claim form as only one charge can be entered.

When entering the charge amount, enter the amount in the field to the left of the vertical line. Enter number

right justified to the left of the vertical line. Enter 00 for cents if the amount is a whole number. Do not use

dollar signs, commas, or a decimal point when reporting amounts. Negative dollar amounts are not allowed.

Leave the right-hand field blank.

Description: “Outside lab? $Charges” reports the costs related to services rendered by an independent

provider as indicated in Item Number 32.

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:

x112500

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:

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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:

Item Number 23

Title: Prior Authorization Number

Instructions: Enter any of the following: prior authorization number or referral number, mammography

pre-certification number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned

by the payer for the current service.

Do not enter hyphens or spaces within the number.

For Workers Compensation and Other Property & Casualty Claims: Required when 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:

7 ABC1234567890

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 and to accommodate the submission of supplemental information to sup-

port the billed service. The top area of the six service lines is shaded and is the location for reporting supple-

mental 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 46 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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09 30 05 09 30 05

Item Number 24A

Title: Date(s) of Service [lines 1–6]

Instructions: Enter date(s) of service, both the “From” and “To” dates. If there is only one date of service,

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 start-

ing 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 46.

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:

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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.gov/physicianfeesched/downloads/Website_POS_database.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:

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Item Number 24C

Title: EMG [lines 1–6]

Instructions: Check with payer 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 4010A1

or 5010A1.

Field Specification: This field allows for the entry of 2 characters in the unshaded area.

Example:

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99241 25

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 med-

ical 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:

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1234

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 appli-

cable 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 rea-

son the service(s) was performed.

Field Specification: This field allows for the entry of 4 characters in the unshaded area.

Example:

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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

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.

5010A1 Instruction: Anesthesia services must be reported as minutes. Units may only be

reported for anesthesia services when the code description includes a time period (such as “daily

management”).

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:

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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 4010A1 and 5010A1:

AV Available – Not Used (Patient refused referral.)

S2 Under Treatment (Patient is currently under treatment for referred diagnostic or corrective health

problem.)

ST 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.)

NU 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:

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Item Number 24I

Title: ID Qualifier [lines 1–6]

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 used in 4010A1 and 5010A1:

The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identi-

fiers 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, classifica-

tion, 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.

4010A1 5010A1

0B State License Number 0B State License Number

1B Blue Shield Provider Number 1G Provider UPIN Number

1C Medicare Provider Number G2 Provider Commercial Number

1D Medicaid Provider Number LU Location Number

1G Provider UPIN Number ZZ Provider Taxonomy (The qualifier in the 5010A1 for

Provider Taxonomy is PXC, but ZZ will remain the qual-

ifier for the 1500 Claim Form. Note: This identier is not

included in this data element in 5010A1.)

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

G2 Provider Commercial Number

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Field Specification: This field allows for the entry of a 2 character qualifier in the shaded area.

Example:

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Item Number 24J

Title: Rendering Provider ID # [lines 1–6]

Instructions: The individual rendering the service is reported in 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 (5010A1: Reporting anesthesia

duration time does not exist in 5010A1. The NUCC recommends that this not be reported.)

• 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 Anesthesia information (5010A1: Reporting anesthesia duration time does not exist in 5010A1. The

NUCC recommends that this not be reported.)

ZZ Narrative description of unspecified code

N4 National Drug Codes (NDC)

VP 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

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 International Unit ML Milliliter

GR Gram UN 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:

Anesthesia Services, when payment based on minutes as units:

Unspecified Code:

NDC Code:

Vendor Product Number Health Industry Business Communications Council (HIBCC):

Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN):

ZZKaye Walker N G2 12345678901

10 01 05 10 01 05 12 E1399 12 165 00 1 N 0123456789

N459148001665 UN1 N G2 12345678901

10 01 05 10 01 05 11 J0400 1 250 00 40 N 0123456789

VPA122BIC5D6E7G 1 N G2 12345678901

10 01 05 10 01 05 11 A6410 13 15 00 1 N 0123456789

7Begin 1245 End 1415 N G2 12345678901

10 01 05 10 01 05 22 00770 P2 134 875 00 90 N 0123456789

7Begin 1245 End 1415 Time 90 minutes N G2 12345678901

10 01 05 10 01 05 22 00770 P2 134 875 00 6 N 0123456789

N449500267230 UN1 50.00 N G2 12345678901

10 01 05 10 01 05 11 J7603 1 50 00 2.5 N 0123456789

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Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN):

Tooth Number:

Multiple Tooth Numbers:

Area of Oral Cavity:

Multiple Areas of Oral Cavity:

JO10 20 N G2 12345678901

10 01 05 10 01 05 11 D7310 1 500 00 2 N 0123456789

JP1 16 17 32 N G2 12345678901

10 01 05 10 01 05 11 D7240 1 500 00 4 N 0123456789

OXZ00301134678906 2 N G2 12345678901

10 01 05 10 01 05 12 A6410 13 500 00 2 N 0123456789

JP1 N G2 12345678901

10 01 05 10 01 05 11 D7240 1 500 00 1 N 0123456789

JO10 N G2 12345678901

10 01 05 10 01 05 11 41820 1 500 00 1 N 0123456789

Item Number 25

Title: Federal Tax ID Number

Instructions: Enter the “Federal Tax ID Number” (employer identification number or Social Security num-

ber) 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:

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 account-

ing system.

Do not enter hyphens with numbers. Enter numbers left justified in the field.

Description: The “Patient’s Account No.” refers to the identifier assigned by the provider.

Field Specification: This field allows for the entry of 14 characters.

Example:

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12341234

Item Number 27

Title: Accept Assignment?

Instructions: Enter an X in the correct box. Only one box can be marked.

5010A1 Instruction: Report “Accept Assignment?” for all payers.

Description: The accept assignment indicates that the provider agrees to accept assignment under the terms

of the payer’s program.

Field Specification: This field allows for the entry of 1 character in either box.

Example:

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 charac-

ters to the right of the vertical line.

Example:

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1125 00

Item Number 29

Title: Amount Paid

Instructions: Enter total amount the patient and/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:

Item Number 30

Title: Balance Due

Instructions: “Balance Due” does not exist in 4010A1 or 5010A1. The NUCC recommends that this field

not be used.

If required by a payer to report, 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:

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10 00

1115 00

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

4010A1 and 5010A1.

Enter the legal signature of the practitioner or supplier, signature of the practitioner or supplier representa-

tive, “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:

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Joe Smith MD 09/30/05

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 punctuation (i.e., commas, periods) or other symbols 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 reporting a foreign address, contact payer for specific reporting instructions.

5010A1 Instructions: Report a 9-digit ZIP code. Include the hyphen.

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 4010A1:

0B State License Number

1A Blue Cross Provider Number

1B Blue Shield Provider Number

1C Medicare Provider Number

1D Medicaid Provider Number

1G Provider UPIN Number

1H CHAMPUS Identification Number

G2 Provider Commercial Number

LU Location Number

N5 Provider Plan Network Identification Number

TJ Federal Taxpayer’s Identification Number

X4 Clinical Laboratory Improvement Amendment Number

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 identi-

fiers 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, classifica-

tion, and/or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.

5010A1 Instruction: The NUCC defines the following qualifiers used in 5010A1:

0B State License Number

G2 Provider Commercial Number

LU Location Number

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:

General Hospital

9876 Hospital Street

Anytown IL 60610-9876

5678901234 G2A1234567890

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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 punctuation (i.e., commas, periods) or other symbols 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 reporting a foreign address, contact payer for specific reporting instructions.

5010A1 Instruction: 5010A1 requires the “Billing Provider Address” to be a street address or

physical location. The NUCC recommends that the same requirements be applied here.

Report a 9-digit ZIP code. Include the hyphen.

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 used in 4010A1 and 5010A1:

The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identi-

fiers 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, classifica-

tion, 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:

4010A1 5010A1

0B State License Number 0B State License Number

1A Blue Cross Provider Number G2 Provider Commercial Number

1B Blue Shield Provider Number

1C Medicare Provider Number

1D Medicaid Provider Number

ZZ Provider Taxonomy (The qualifier in the 5010A1 for

Provider Taxonomy is PXC, but ZZ will remain the qual-

ifier for the 1500 Claim Form. Note: This identier is not

included in this data element in 5010A1.)

1G Provider UPIN Number

1H CHAMPUS Identification Number

1J Facility ID Number

B3 Preferred Provider Organization Number

BQ Health Maintenance Organization Code Number

FH Clinic Number

G2 Provider Commercial Number

G5 Provider Site Number

U3 Unique Supplier Identification Number (USIN)

X5 State Industrial Accident Provider Number

ZZ Provider Taxonomy

Physician Practice Inc

1234 Healthcare Street

Anytown IL 60610-1234

9876543210 G2Z5678901234

312 5552222

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REFERENCES

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. Health Care Claim:

Professional (837), 005010X222. Washington Publishing Company, May 2006.

<http:www.wpc-edi.com>.

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. Type 1 Errata to Health

Care Claim: Professional (837), 005010X222A1. Washington Publishing Company, June 2010.

<http:www.wpc-edi.com>.

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APPENDIX A: PROVIDER DEFINITION

The following definitions apply to the provider terms used on the 1500 Claim Form.

Referring Provider

The Referring Provider is the individual who directed the patient for care to the provider rendering the

services being reported.

Examples include, but are not limited to, primary care provider referring to a specialist; orthodontist

referring to an oral and maxillofacial surgeon; physician referring to a physical therapist; provider

referring to a home health agency.

Ordering Provider

The Ordering Provider is the individual who requested the services or items being reported on this

service line.

Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or

supplies.

Rendering Provider

The Rendering Provider is the individual who provided the care. In the case where a substitute provider

(locum tenens) was used, that individual is considered the Rendering Provider.

The Rendering Provider does not include individuals performing services in support roles, such as lab

technicians or radiology technicians.

Supervising Provider

The Supervising Provider is the individual who provided oversight of the Rendering Provider and the care

being reported.

An example includes, but is not limited to, supervision of a resident physician.

Purchased Service Provider

A Purchased Service Provider is an individual or entity that performs a service on a contractual or

reassignment basis for a separate provider who is billing for the service.

Examples of services include, but are not limited to: (a) processing a laboratory specimen; (b) grinding

eyeglass lenses to the specifications of the Rendering Provider; or (c) performing diagnostic testing services

(excluding clinical laboratory testing) subject to Medicare’s anti-markup rule. In the case where a substitute

provider (a locum tenens physician) is used, that individual is not considered a Purchased Service Provider.

APPENDIX B: 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

ICD-10-CM – International Classification of Disease, Revision 10, 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 C: GUIDELINES FOR MODIFYING THE 1500 (08/05) CLAIM FORM

The following are the National Uniform Claim Committee’s (NUCC) recommended guidelines for making mod-

ifications 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 pre-

printed 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 loca-

tion 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 D: 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 D). The request/

form can then be emailed to the NUCC at info@nucc.org.

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 D – 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: No:

If Yes, please provide

Organization / Entity Name:

3. Is this request for an instruction revision or deletion?

Revision: Deletion:

Go to Question 4 Go to Question 8

4. Specify current 1500 claim

form Item # to be REVISED.

5. Description of proposed revision

Check here ___ if continued on a separate sheet

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Item # Page

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.

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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Item # Page

Claim Form Manual V7 0 7 11

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