| 1 | Type of Insurance | Mark an “X” in the subscriber’s corresponding health insurance type. Only one box can be marked.
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| 1a* | Insured’s I.D. Number (patient) | Enter the Member identification number exactly as it appears on the patient’s ID card. The member’s ID number is the subscriber number and the two-digit suffix listed next to the member’s name on the ID card. |
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| 2* | Patient’s Name | Enter the last name, first name, and middle initial of the patient. |
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| 3* | Patient’s Birth Date, Sex | Enter the patient’s date of birth (MM/DD/YYYY) and an “X” in appropriate box (M or F). If sex is unknown, leave blank. |
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| 4 | Insured’s Name (subscriber) | Enter the last name, first name, and middle initial of insured. |
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| 5* | Patient’s Address (multiple fields)
| Enter the number, street, city, state, ZIP code, and telephone number (including area code) of the patient. |
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| 6* | Patient Relationship to Insured | Mark an “X” in appropriate box (self, spouse, child, or other). |
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| 7* | Insured’s Address | Enter the number, street, city, state, ZIP code, and telephone number (including area code) of insured member. If the insured’s address is the same as Field 5, enter “Same.” |
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| 8 | Reserved for NUCC Use | Field not used. |
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| 9* | Other Insured’s Name | If there is a holder of another policy that may cover the patient, enter the other insured’s last name, first name, and middle initial, if different from that shown in Field 2. |
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| 9a* | Other Insured’s Policy or Group Number | Enter the other insured’s policy/and or group number identified in Field 9. |
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| 9b | Reserved for NUCC Use | Field not used. |
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| 9c | Reserved for NUCC Use | Field not used. |
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| 9d* | Insurance Plan Name or Program Name | Enter the insurance plan name or program name of the other insured identified in Field 9. |
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| 10a* - 10c* | Is Patient’s Condition Related to: | Check “Yes” or “No” to indicate whether (a) Employment, (b) Auto Accident, or (c) Other Accident applies to any of the services described in Field 24. |
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| 10d | Claim Codes (Designated by NUCC) | When applicable, use this field to report appropriate claim codes designated by NUCC. When reporting more than one code, enter three blank spaces and then the next code. |
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| 11 | Insured’s Policy Group or FECA Number | Enter the insured’s policy, group, or FECA (Federal Employees Compensation Act) number from their identification card. |
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| 11a | Insured’s Date of Birth and Sex
| Enter the insured’s date of birth (MM/DD/YYYY) and an “X” in appropriate box (M or F) from Field 1a. Only one box can be marked. If gender is unknown, leave it blank. |
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| 11b | Other Claim ID (Designated by NUCC) | Enter the other claim identifiers applicable to the claim. Applicable claim identifiers are designated by the NUCC. |
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| 11c | Insurance Plan Name or Program Name
| Enter the insurance plan name or program name referring to Field 1a.
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| 11d | Is There Another Health Benefit Plan? | Indicate by an “X” that the patient does or does not have insurance coverage other than the plan indicated in Field 1. If marked “yes,” complete Fields 9, 9a, and 9d. |
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| 12 | Patient’s or Authorized Person’s Signature and Date | Enter “Signature of File,” “SOF,” or legal signature. When legal signature, enter date (MM/DD/YYYY). This field indicates there is authorization on file for release of any medical or other information necessary
to process the claim. If there is no signature |
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| 13 | Insured’s or Authorized Person’s Signature
| Enter “Signature of File,” “SOF,” or legal signature. This field indicates a signature on file authorizing payment of medical benefits. If there is no signature on file, leave blank or enter “No signature
on file.” |
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| 14 | Date of Current: Illness, Injury, or Pregnancy (LMP)
| Enter the first date (MM/DD/YYYY) 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 the right of the vertical, dotted line.
Use “431” for onset of current symptoms or illness, or “484” for LMP.
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| 15 | Other Date | Enter another date (MM/DD/YYYY) related to the patient’s condition and treatment. 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
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| 16 | Dates Patient Unable to Work in Current Occupation | Enter if the patient is employed and is unable to work in current occupation. Enter “from” and “to” dates (MM/DD/YYYY), indicating the dates the patient is unable to work. |
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| 17* | Name of Referring Provider or Other Source Please note: Fields 17, 17a, and 17b are only mandatory if there is a referring provider. If there is not one, leave it blank.
| 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 there is no referring provider or if a self-referral, please leave
all of Field 17 (including 17a and 17b) blank. If there are multiple providers involved, enter one provider using the following priority order: - Referring Provider
- Ordering Provider
- Supervising Provider
Additionally, enter the
applicable qualifier to identify which provider is being reported: - “DN” – Referring Provider
- “DK” – Ordering Provider
- “DQ” – Supervising Provider
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| 17a* | Other ID# | Enter the non-NPI ID number of the referring, ordering, or supervising provider that will be the unique identifier of the provider-designated taxonomy code. Enter the two-digit qualifier before the other ID number. Qualifiers are: - “0B”
– State License Number
- “1G” – Provider UPIN Number
- “G2” – Provider Commercial Number
- “LU” – Location Number (Supervising Provider Only)
If the provider does
not have a unique identifier, leave it blank.
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| 17b* | NPI of Referring Physician | Enter the NPI of the referring, ordering, or supervising provider listed in Field 17. |
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| 18 | Hospitalization Dates Related to Current Services | Enter the inpatient hospital admission date (MM/DD/YYYY) followed by the discharge date (if discharge has occurred). If no discharge date, leave discharge date blank.
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| 19 | Additional Claim Information (Designated by NUCC) | For the Claim Information (NTE), the following are the qualifiers in 5010A1. Enter the qualifier “NTE,” followed by the appropriate qualifier, then the information. Do not enter spaces between the qualifier and the first
word of the information. After the qualifier, use spaces to separate any words. - ADD Additional Information
- CER Certification Narrative
- DCP Goals, Rehabilitation Potential, or Discharge Plans
- DGN Diagnosis Description
- TPO Third Party Organization Notes
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| 20 | Outside Lab? $ Charges | Complete this field when billing for purchased services by entering an “X” in “Yes.” This indicates that the reported service was provided by an entity other than the billing provider. |
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| 21* | Diagnosis or Nature of Illness or Injury | Enter the applicable ICD indicator (upper right-hand of the box) to identify which version of ICD codes is being reported. - “9” – ICD-9-CM
- “0” – ICD-10-CM
Enter the codes to identify the patient’s
diagnosis and/or condition. List no more than 12 ICD-10-CM or ICD-9-CM diagnosis codes in lines A – L. IMPORTANT – You cannot mix ICD-10-CM codes and ICD-9-CM codes on the same claim. It must be submitted with either all ICD-10-
CM codes or all ICD-9-CM codes.
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| 22 | Resubmission and/or Original Reference Number
| List the original claim number for previously submitted claims. 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
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| 23 | Prior Authorization Number
| Enter the prior authorization number, referral number, mammography precertification number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service. |
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| 24a* | Date(s) of Service – Lines 1 through 6
| Enter the date(s) of service (MM/DD/YY) in both the “From” and “To” dates. If there is only one date of service, enter that date under “From.” Use the grey space above the date to enter any NDC codes. NDC
should be entered in the following order: “N4” qualifier, the NDC code, one space, unit/basis of measurement qualifier*, and quantity. Do not use decimals or commas.
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| 24b* | Place of Service – Lines 1 through 6 | Enter the appropriate two-digit code from the Place of Service Code List for each item used or service performed. You can find the Place of Service Code List at www.cms.gov.
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| 24c | EMG – Lines 1 through 6 | If the service(s) rendered is for an emergency, enter “Y” for “Yes” or leave blank if “No” in the bottom, unshaded area of the field. |
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| 24d* | Procedures, Services, or Supplies –Lines 1 through 6
| Enter the CPT® or HCPCS© code(s) and any applicable modifier(s) from the appropriate code set in effect on the date of service. This field identifies the medical services and procedures provided to the patient. |
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| 24e* | Diagnosis Pointer – Lines 1 through 6 | Enter the diagnosis code reference letter (pointer) as shown in Field 21 to relate the date of service and the procedures performed to the primary diagnosis. The reference letter(s) should be A-L or multiple letters as applicable.
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| 24f* | $Charges – Lines 1 through 6 | Enter monetary charge for each listed service. Do not use commas when reporting dollar amounts. Dollar signs should not be entered. Enter “00” in the cents area if the amount is a whole number.
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| 24g* | Days or Units – Lines 1 through 6 | Enter the number of days or units. If only one service is performed, the numeral “1” must be entered. No leading zeros are required. If reporting a fraction of a unit, use the decimal point. |
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| 24h | EPSDT Family Plan – Lines 1 through 6 | Used for Early & Periodic Screening, Diagnosis, and Treatment related services. |
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| 24i | ID Qualifier – Lines 1 through 6 | If the provider does not have an NPI number, enter the qualifier identifying that the number is a non-NPI in the shaded area. |
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| 24j* | Rendering Provider ID# – Lines 1 through 6 | Enter the NPI of the rendering provider in the unshaded area. If the provider does not have an NPI number, enter the non-NPI number in the shaded area. |
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| 25* | Federal Tax ID Number
| Enter the Federal Tax ID Number (employer ID number or SSN) of the Billing Provider identified in Field 33. This is the tax ID number intended to be used for 1099 reporting purposes. Ensure the appropriate box is checked to indicate if a NPI
or SSN is being reported.
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| 26 | Patient’s Account Number | Enter the patient’s account number assigned by the provider of service’s or supplier’s accounting system. |
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| 27 | Accept Assignment?
| Mark an “X” in the appropriate box (Yes or No) to indicate whether the provider of services or supplier accepts assignment under the terms of the payer’s program. |
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| 28* | Total Charge
| Enter the total charges for the services (total of all charges in Field 24f). Do not use commas when reporting dollar amounts. Dollar signs should not be entered. Enter “00” in the cents area if the amount is a whole number. |
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| 29 | Amount Paid | Enter the payment received from the patient and/or other payers. |
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| 30 | Reserved for NUCC Use | Field not used. |
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| 31* | Signature of Physician or Supplier Including Degrees or Credentials | Enter the legal signature, date, and degree/credentials of the physician/provider/supplier of the services (or authorized representative), “Signature on File” or “SOF.” Enter the date (MM/DD/YYYY) the form was signed. |
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| 32* | Service Facility Location Information
| Enter the name, address, and ZIP code of the location where the services were rendered. Providers are required to report the most appropriate place of service on claim submissions. To ensure proper processing
and reimbursement for your claims, please make sure you are accurately entering the appropriate Place of Service (POS) address for all claims submitted. Do not include mail codes. Enter place of service addresses in alignment with USPS
address format. When submitting multiple claims for a specific practice location, be sure to enter the address consistently across all claims. Box 32 may be blank if it is the same as Box 33.
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| 32a* | NPI# | Enter the NPI number of the service facility location from Field 32. |
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| 32b | Other ID# | Enter the two-digit qualifier identifying the non-NPI number followed by the ID number. |
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| 33* | Billing Provider Info & PH# | Enter the provider’s or supplier’s billing name, address, ZIP code, and phone number. If a P.O. Box is entered, there must also be a physical address in Box 32. P.O. box is not accepted on paper claims. Enter addresses in alignment
with USPS address format. When submitting multiple claims for a specific billing provider, be sure to enter the address consistently across all claims. Must be a single pay to address for each unique combination of NPI and TIN.
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| 33a* | NPI# | Enter the NPI of the billing provider from Field 33. If 33a is a group NPI, the TIN and NPI must match the organization.
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| 33b | Other ID# | Enter the two-digit qualifier identifying the non-NPI number followed by the ID number. |
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