1500 Health Insurance Claim Form Reference Instruction Manual for

Version 1.1

06/13

National Uniform Claim Committee

1500 Health Insurance Claim Form

Reference Instruction Manual

for Form Version 02/12

June 2013

Version 1.1 06/13

Version 1.1

02/13

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 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 (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 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 expressed or implied. The

AMA and the NUCC and its members shall not be responsible for any use or non use of this document.

Version 1.1

02/13

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 23

Reference 56

Appendix A: Provider Definitions 57

Appendix B: Abbreviations 58

Appendix C: Guidelines for Modifying the 1500 (02/12) Claim Form 60

Appendix D: Maintenance of the 1500 Reference Instruction Manual 61

Version 1.1

02/13

1500 CLAIM FORM INSTRUCTIONS: BACKGROUND INFORMATION

The 1500 Health Insurance Claim Form (1500 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, however, 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.

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 Accredited Standards Committee X12

(ASC X12) 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 1500 Claim Form instructions were initially approved by the NUCC in November 2005. The NUCC

continues to research the type of data that are typically reported, as well as the required data elements

that may apply to public and private payers. Therefore, the instructions 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

requirements.

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

requirements.

Version 1.1

02/13

Version 1.1

02/13

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 12 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.

NOTE: Form images throughout this manual may not be to scale.

Version 1.1

02/13

FIELD SPECIFIC INSTRUCTIONS

CARRIER BLOCK

The carrier block is located in the upper center and right margin of the form. In order to distinguish this

version of the form from previous versions, the Quick Response (QR) code symbol and the date

approved by the NUCC have been added to the top, left-hand 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:

Line – Name

Line – First line of address

Line – Second line of address, if necessary

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 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

DESCRIPTION: The payer is the carrier, health plan, third-party administrator, or other payer that will

handle the claim. This information directs the claim to the appropriate payer.

Version 1.1

02/13

EXAMPLES:

Four line address:

Three line address:

Version 1.1

02/13

ITEMS 1–13: PATIENT AND INSURED INFORMATION

Note: 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, 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, CHAMPVA, Group Health Plan, FECA, Black Lung, Other”

means the insurance type to which 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 the insured’s ID number as shown on insured’s ID card for the payer to which 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 AND CASUALTY CLAIMS: Enter the Federal Tax ID or SSN of the insured person or

entity.

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

identifies the insured to the payer.

FIELD SPECIFICATION: This field allows for entry of 29 characters.

EXAMPLE:

Version 1.1

02/13

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

necessary 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 | YYYY). Enter an X in the correct box to

indicate sex (gender) of the patient. Only one box can be marked. If sex is unknown, leave blank.

DESCRIPTION: The “Patient’s Birth Date, Sex” 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:

Version 1.1

02/13

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:

Version 1.1

02/13

ITEM NUMBER 5

TITLE: Patient’s Address (multiple fields)

INSTRUCTIONS: Enter the patient’s address. The first line is for the street address; the second line, the

city and state; the third line, the 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). 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 5010A1. The NUCC recommends that the phone number not be

reported. Phone extensions are not supported.

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” is 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:

Version 1.1

02/13

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.

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.

DESCRIPTION: The “Patient Relationship to Insured” indicates 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:

Version 1.1

02/13

ITEM NUMBER 7

TITLE: Insured’s Address (multiple fields)

INSTRUCTIONS: Enter the insured’s address. 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.

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 5010A1. The NUCC recommends that the phone number not be

reported. Phone extensions are not supported.

FOR WORKERS COMPENSATION CLAIMS: Enter the address of the Employer.

FOR OTHER PROPERTY AND CASUALTY CLAIMS: Enter the address of the insured noted in Item Number

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” is 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:

Version 1.1

02/13

ITEM NUMBER 8

TITLE: Reserved for NUCC Use

INSTRUCTIONS: This field was previously used to report “Patient Status.” “Patient Status” does not exist

in 5010A1, so this field has been eliminated.

This field is reserved for NUCC use. The NUCC will provide instructions for any use of this field.

DESCRIPTION: This field is reserved for NUCC use.

FIELD SPECIFICATION: None

EXAMPLE: None

ITEM NUMBER 9

TITLE: Other Insured’s Name

Instructions: If Item Number 11d is marked, complete fields 9, 9a, and 9d, 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:

Version 1.1

02/13

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:

ITEM NUMBER 9b

TITLE: Reserved for NUCC Use

INSTRUCTIONS: This field was previously used to report “Other Insured’s Date of Birth, Sex.” “Other

Insured’s Date of Birth, Sex” does not exist in 5010A1, so this field has been eliminated.

This field is reserved for NUCC use. The NUCC will provide instructions for any use of this field.

DESCRIPTION: This field is reserved for NUCC use.

FIELD SPECIFICATION: None

EXAMPLE: None

Version 1.1

02/13

ITEM NUMBER 9c

TITLE: Reserved for NUCC Use

INSTRUCTIONS: This field was previously used to report “Employer’s Name or School Name.”

“Employer’s Name or School Name” does not exist in 5010A1, so this field has been eliminated.

This field is reserved for NUCC use. The NUCC will provide instructions for any use of this field.

DESCRIPTION: This field is reserved for NUCC use.

FIELD SPECIFICATION: None

EXAMPLE: None

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:

Version 1.1

02/13

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 where the accident occurred 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:

Version 1.1

02/13

ITEM NUMBER 10d

TITLE: Claim Codes (Designated by NUCC)

INSTRUCTIONS: When applicable, use to report appropriate claim codes. Applicable claim codes are

designated by the NUCC. Please refer to the most current instructions from the public or private payer

regarding the need to report claim codes.

When required by payers to provide the 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.

When reporting more than one code, enter three blank spaces and then the next code.

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.

DESCRIPTION: The “Claim Codes” identify additional information about the patient’s condition or the

claim.

FIELD SPECIFICATION: This field allows for the entry of 19 characters.

EXAMPLE:

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.

DESCRIPTION: The “Insured’s Policy, Group, or FECA Number” is 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:

Version 1.1

02/13

ITEM NUMBER 11a

TITLE: Insured’s Date of Birth, Sex

INSTRUCTIONS: Enter the 8-digit date of birth (MM│DD│YYYY) of the insured and an X to indicate the sex

(gender) of the insured. Only one box can be marked. If gender is unknown, leave blank.

DESCRIPTION: The “Insured’s Date of Birth, Sex” is 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: Other Claim ID (Designated by NUCC)

INSTRUCTIONS: Enter the “Other Claim ID.” Applicable claim identifiers are designated by the NUCC.

The following qualifier and accompanying identifier has been designated for use:

Y4 Property Casualty Claim Number

Enter the qualifier to the left of the vertical, dotted line. Enter the identifier number to the right of the

vertical, dotted line.

FOR WORKERS’ COMPENSATION OR PROPERTY & CASUALTY: Required if known. Enter the claim

number assigned by the payer.

DESCRIPTION: The “Other Claim ID” is another identifier applicable to the claim.

FIELD SPECIFICATION: This field allows for the entry of the following: 2 characters to the left of the

vertical, dotted line and 28 characters to the right of the dotted line.

EXAMPLE:

Version 1.1

02/13

ITEM NUMBER 11c

TITLE: Insurance Plan Name or Program Name

INSTRUCTIONS: Enter the name of the insurance plan or program 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” is 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, 9a, and

9d. 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:

Version 1.1

02/13

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 (MM|DD|YY) or 8-digit format (MM|DD|YYYY) format. 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:

Version 1.1

02/13

ITEMS 14–33: PHYSICIAN OR SUPPLIER INFORMATION

ITEM NUMBER 14

TITLE: Date of Current Illness, Injury, or Pregnancy (LMP)

INSTRUCTIONS: Enter the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) 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.

Enter the applicable qualifier to identify which date is being reported.

431 Onset of Current Symptoms or Illness

484 Last Menstrual Period

Enter the qualifier to the right of the vertical, dotted line.

DESCRIPTION: The “Date of Current Illness, Injury, or Pregnancy” identifies 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, 4 characters under YY, and 3 characters to the right of the vertical, dotted line.

EXAMPLE:

Version 1.1

02/13

ITEM NUMBER 15

TITLE: Other Date

INSTRUCTIONS: Enter another date related to the patient’s condition or treatment. Enter the date in the

6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) format.

Enter the applicable qualifier to identify which date is being reported.

454 Initial Treatment

304 Latest Visit or Consultation

453 Acute Manifestation of a Chronic Condition

439 Accident

455 Last X-ray

471 Prescription

090 Report Start (Assumed Care Date)

091 Report End (Relinquished Care Date)

444 First Visit or Consultation

Enter the qualifier between the left-hand set of vertical, dotted lines.

DESCRIPTION: The “Other Date” identifies additional date information about the patient’s condition or

treatment.

FIELD SPECIFICATION: This field allows for the entry of the following: 3 characters between the vertical,

dotted lines, 2 characters under MM, 2 characters under DD, and 4 characters under YY.

EXAMPLE:

Version 1.1

02/13

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│YYYY) 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” is 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:

Version 1.1

02/13

ITEM NUMBER 17

TITLE: Name of Referring Provider or Other Source

INSTRUCTIONS: Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of

the professional who referred or ordered 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. A hyphen can be used for hyphenated names.

Enter the applicable qualifier to identify which provider is being reported.

DN Referring Provider

DK Ordering Provider

DQ Supervising Provider

Enter the qualifier to the left of the vertical, dotted line.

DESCRIPTION: The name entered is the referring provider, ordering provider, or supervising provider

who referred, ordered, or supervised the service(s) or supply(ies) on the claim. The qualifier indicates

the role of the provider being reported.

FIELD SPECIFICATION: This field allows for the entry of 2 characters to the left of the vertical, dotted line

and 24 characters to the right of the dotted line.

EXAMPLE:

Version 1.1

02/13

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 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 is the unique

identifier of the professional or 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:

Version 1.1

02/13

ITEM NUMBER 18

TITLE: Hospitalization Dates Related to Current Services

INSTRUCTIONS: Enter the inpatient 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) 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:

Version 1.1

02/13

ITEM NUMBER 19

TITLE: Additional Claim Information (Designated by NUCC)

INSTRUCTIONS: Please refer to the most current instructions from the 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 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.)

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 qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ

will remain the qualifier for the 1500 Claim Form.)

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.

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

used in 5010A1:

REPORT TYPE CODES

03 Report Justifying Treatment Beyond Utilization

04 Drugs Administered

05 Treatment Diagnosis

06 Initial Assessment

07 Functional Goals

08 Plan of Treatment

09 Progress Report

10 Continued Treatment

11 Chemical Analysis

13 Certified Test Report

15 Justification for Admission

21 Recovery Plan

Version 1.1

02/13

A3 Allergies/Sensitivities Document

A4 Autopsy Report

AM Ambulance Certification

AS Admission Summary

B2 Prescription

B3 Physician Order

B4 Referral Form

BR Benchmark Testing Results

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 Records

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

PZ 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 CODES

AA Available on Request at Provider Site

BM By Mail

Version 1.1

02/13

Example: PWK03AA12363545465

DESCRIPTION: “Additional Claim Information” identifies additional information about the patient’s

condition or the claim.

FIELD SPECIFICATION: This field allows for the entry of 71 characters.

EXAMPLE: None

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

purchased 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” 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 and 2 characters to the right of the

vertical line in the $Charges area.

EXAMPLE:

Version 1.1

02/13

ITEM NUMBER 21

TITLE: Diagnosis or Nature of Illness or Injury

INSTRUCTIONS: Enter the applicable ICD indicator to identify which version of ICD codes is being

reported.

9 ICD-9-CM

0 ICD-10-CM

Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field.

Enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD-9-CM or

ICD-10-CM diagnosis codes. Relate lines A - L to the lines of service in 24E by the letter of the line. Use

the highest level of specificity. Do not provide narrative description in this field.

DESCRIPTION: The “ICD Indicator” identifies the version of the ICD code set being reported. The

“Diagnosis or Nature of Illness or Injury” is 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 a 1 character indicator and 12 diagnosis codes at a

maximum of 7 characters in length.

EXAMPLE:

Version 1.1

02/13

ITEM NUMBER 22

TITLE: Resubmission and/or Original Reference Number

INSTRUCTIONS: List the original reference number for resubmitted claims. Please refer to the most

current instructions from the 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: “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, 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.

DESCRIPTION: The “Prior Authorization Number” is the payer assigned number authorizing the

service(s).

FIELD SPECIFICATION: This field allows for the entry of 29 characters.

EXAMPLE:

Version 1.1

02/13

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 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 45 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 39 characters from

the beginning of 24A to the end of 24G.

Version 1.1

02/13

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 narrative description of an unspecified code, NDC,

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 45.

DESCRIPTION: “Date(s) of Service” indicates 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:

Version 1.1

02/13

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:

Version 1.1

02/13

ITEM NUMBER 24C

TITLE: EMG [lines 1–6]

INSTRUCTIONS: Check with payer to determine if this information (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 5010A1.

DESCRIPTION: “EMG” identifies if the service was an emergency.

FIELD SPECIFICATION: This field allows for the entry of 2 characters in the unshaded area.

EXAMPLE:

Version 1.1

02/13

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: “Procedures, Services or Supplies” identify the medical services and procedures provided

to the patient.

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:

Version 1.1

02/13

ITEM NUMBER 24E

TITLE: Diagnosis Pointer [lines 1–6]

INSTRUCTIONS: In 24E, enter the diagnosis code reference letter (pointer) as shown in Item Number 21

to relate the date of service and the procedures performed to the primary diagnosis. When multiple

services are performed, the primary reference letter for each service should be listed first, other

applicable services should follow. The reference letter(s) should be A – L or multiple letters as applicable.

ICD-9-CM (or ICD-10-CM, once mandated) diagnosis codes must be entered in Item Number 21 only. Do

not enter them in 24E.

Enter letters left justified in the field. Do not use commas between the letters.

DESCRIPTION: The “Diagnosis Pointer” is the line letter 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:

Version 1.1

02/13

ITEM NUMBER 24F

TITLE: $Charges [lines 1–6]

INSTRUCTIONS: Enter the charge for each listed service.

Enter the 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” is 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:

Version 1.1

02/13

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 left justified in the field. No leading zeros are required. If reporting a fraction of a unit,

use the decimal point.

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” is 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:

Version 1.1

02/13

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 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.

EXAMPLE:

Version 1.1

02/13

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 should be reported in 24J in the shaded area.

The NUCC defines the following qualifiers used in 5010A1:

0B State License Number

1G Provider UPIN Number

G2 Provider Commercial Number

LU Location Number

ZZ Provider Taxonomy (The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ

will remain the qualifier for the 1500 Claim Form.)

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:

Version 1.1

02/13

ITEM NUMBER 24J

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

INSTRUCTIONS: The individual rendering the service should be 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 individual performing/rendering the service should be reported in 24J and the

qualifier indicating if the number is a non-NPI is reported in 24I. The non-NPI ID number of the rendering

provider refers to the payer assigned unique identifier of the professional.

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:

Version 1.1

02/13

INSTRUCTIONS AND EXAMPLES OF SUPPLEMENTAL INFORMATION IN ITEM

NUMBER 24

The following are types of supplemental information that can be entered in the shaded areas of Item

Number 24:

• Narrative description of unspecified codes

• National Drug Codes (NDC) for drugs

• Contract rate

• Tooth numbers and areas of the oral cavity

The following qualifiers are to be used when reporting these services.

ZZ Narrative description of unspecified code

N4 National Drug Codes (NDC)

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

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 ME Milligram UN Unit

GR Gram ML Milliliter

Version 1.1

02/13

When reporting compound drugs, a statement of ingredients may be required to be attached to the

claim.

The following qualifiers are to be used when regulations mandate the use of the Universal Product

Number (UPN) for reporting medical and surgical supplies:

EN EAN/UCC - 13

EO EAN/UCC - 8

HI HIBC (Health Care Industry Bar Code)

Supplier Labeling Standard Primary Data Message

UK GTIM 14 - digit data structure

UP UCC - 12

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

For further information on these codes, refer to the Current Dental Terminology (CDT) Manual available

from the American Dental Association.

Version 1.1

02/13

EXAMPLES

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.

UNSPECIFIED CODE:

NDC CODE:

TOOTH NUMBER:

MULTIPLE TOOTH NUMBERS:

AREA OF ORAL CAVITY:

MULTIPLE AREAS OF ORAL CAVITY:

Version 1.1

02/13

ITEM NUMBER 25

TITLE: Federal Tax ID Number

INSTRUCTIONS: Enter the “Federal Tax ID Number” (employer ID number or SSN) 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” is 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

accounting system.

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

DESCRIPTION: The “Patient’s Account No.” is the identifier assigned by the provider.

FIELD SPECIFICATION: This field allows for the entry of 14 characters.

EXAMPLE:

Version 1.1

02/13

ITEM NUMBER 27

TITLE: Accept Assignment?

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

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 the 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” is 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:

Version 1.1

02/13

ITEM NUMBER 29

TITLE: Amount Paid

INSTRUCTIONS: Enter total amount the patient and/or other payers paid on the covered services only.

Enter the 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” is 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: Reserved for NUCC Use

INSTRUCTIONS: This field was previously used to report “Balance Due.” “Balance Due” does not exist in

5010A1, so this field has been eliminated.

This field is reserved for NUCC use. The NUCC will provide instructions for any use of this field.

DESCRIPTION: This field is reserved for NUCC use.

FIELD SPECIFICATION: None

EXAMPLE: None

Version 1.1

02/13

ITEM NUMBER 31

TITLE: Signature of Physician or Supplier Including Degrees or Credentials

INSTRUCTIONS: “Signature of Physician or Supplier Including Degrees or Credential” does not exist in

5010A1.

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|YYYY), 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:

Version 1.1

02/13

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.

If the “Service Facility Location” is a component or subpart of the Billing Provider and they have their

own NPI that is reported on the claim, then the subpart is reported as the Billing Provider and “Service

Facility Location” is not used. When reporting an NPI in the “Service Facility Location,” the entity must be

an external organization to the Billing Provider.

Enter the name and address information in the following format:

Line – Name

Line – Address

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. Report a 9-digit ZIP code, including the hyphen.

If reporting 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.

Only report a Service Facility Location NPI when the NPI is different from the Billing Provider NPI.

DESCRIPTION: The NPI number refers to the HIPAA National Provider Identifier number.

FIELD SPECIFICATION: This field allows for the entry of 10 characters.

Version 1.1

02/13

TITLE 32B: Other ID#

INSTRUCTIONS: Enter the 2-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 5010A1:

0B State License Number

G2 Provider Commercial Number

LU Location Number

DESCRIPTION: The non-NPI ID number of the service facility is the payer assigned unique identifier of the

facility.

FIELD SPECIFICATION: This field allows for the entry of 14 characters in 32b.

EXAMPLE:

Version 1.1

02/13

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:

Line – Name

Line – Address

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. Report a 9-digit ZIP code, including 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 requires the “Billing Provider Address” be a street address or physical location. The NUCC

recommends that the same requirements be applied here.

DESCRIPTION: The billing provider’s or supplier’s billing name, address, ZIP code, and phone number is

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 87 characters 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.

Version 1.1

02/13

TITLE 33B: Other ID#

INSTRUCTIONS: Enter the 2-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 5010A1:

0B State License Number

G2 Provider Commercial Number

ZZ Provider Taxonomy (The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ

will remain the qualifier for the 1500 Claim Form.)

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 billing provider refers to the payer assigned unique

identifier of the professional.

FIELD SPECIFICATION: This field allows for the entry of 17 characters in 33b.

EXAMPLE:

Version 1.1

02/13

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>.

Version 1.1

02/13

APPENDIX A: PROVIDER DEFINITIONS

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

5010 837P

The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In

the case where a substitute provider (locum tenens) was used, enter that provider's information here.

Future Versions of 837P

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.

Version 1.1

02/13

APPENDIX B: ABBREVIATIONS

AMA – American Medical Association

BLK Lung – Black Lung

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, 4

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 – Internal Classification of Disease, Revision 9, Clinical Modification

ICD-10-CM - Internal Classification of Disease, Revision 10, Clinical Modification

I.D. or ID – Identification

I.D. # or ID# – Identification Number

INFO – Information

Version 1.1

02/13

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

YYYY – Year, indicates entry of four digits for the year (YYYY)

Version 1.1

02/13

APPENDIX C: GUIDELINES FOR MODIFYING THE 1500 (02/12) CLAIM FORM

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

modifications to the 1500 (02/12) 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.

Version 1.1

02/13

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: i[email protected]rg

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 ASC X12 Health Care Claim:

Professional (837) Technical Report Type 3 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.

Version 1.1

02/13

ATTACHMENT 1 TO APPENDIX D – 1500 CLAIM FORM INSTRUCTIONS

CHANGE REQUEST FORM

Version 1.1

02/13