1

Type of Health
Insurance

2000B

SBR01

Receiving Payer Responsibility (P = Primary, S = Secondary T = Tertiary)

SBR02

Individual relationship code (18 = Self is required)

SBR09

Receiving Payer

(MB=Medicare Part B is required)

1a

Patient’s Medicare
Beneficiary ID Number

2010BA

NM109

Subscriber Primary Identifier

(Information can be found on the patient’s Medicare card.)

2

Patient’s Name
(Enter as it appears
on the Medicare card)

2010BA

NM103

Last name

NM104

First name

NM105

Middle name

NM107

Suffix (e.g., Jr. Sr.)

3

Patient’s Birth Date
and Gender

2010BA

DMG02

Birth Date

DMG03

Gender

4

Insured’s Name
(Complete for Medicare Secondary Payer (MSP) claims)

2330A

NM103

Last name

NM104

First name

NM105

Middle name

5

Patient’s Address

2010BA

N301

Address line 1

N302

Address line 2

N401

City

N402

State Code

N403

ZIP code

6

Patient’s relationship
to the insured
(Complete for MSP claims)

2000B

SBR02

Self-relationship (18 = Self is required)

2320

SBR02

For other insurance, any patient relations can be used depending on who owns the insurance.

7

Insured’s address
(Complete for MSP
claims)

2330A

N301

Address line 1

N302

Address line 2

N401

City

N402

State Code

N403

ZIP Code

9

Name of Enrollee in 
Medigap

2330A

NM103

Last name

NM104

First name

NM105

Middle name

9a

Medigap policy / group 
number

2330A

NM108

Code qualifier

NM109

Insured’s Identifier

2320

SBR01

Payer responsibility

SBR03

Insured’s group / policy no.

9d

The nine-digit payer ID
number of the Medigap insurer or the program name or plan name

2330B

NM108

Payer’s identification qualifier

NM109

Payer last or organization name

NM103

Insured’s group / policy no.

2320

SBR04

Insured’s group name

10

a-c

Is patient’s condition related to employment? Auto accident? Or other accident?

2300

DTP01

Date of accident

CLM11-1

Employment / Auto / Other accident

CLM11-4

Place (State abbreviation)

11

Insured’s policy or group number and / or information

This information should be completed for MSP purposes only

2320

SBR01

Payer responsibility

P = Primary, S = Secondary. T = Tertiary

SBR03

Insured’s group or policy number

2330A

NM108

Identification code qualifier

NM109

Insured’s identifier

2000B

SBR05

Insurance Type Code (for MSP claims only)

Indicator’s must equal one of the following values: 12,13,14,15,16,41,42,43 or 47 if 2000B SBR01 = “T” or “S”

2000B

or

2320

SBR09

Claim filing indicator code. 2000B must be MB. 2320 must be anything other than MB.

2300

CLM01

Claim submitter’s identifier

CLM02

Total Claim Charge Monetary amount

2320

AMT01

Primary Paid Amount qualifier code = D

AMT02

Monetary amount (Primary Paid Claim Level)

11 (cont)

Insured’s policy or group number (continued)

This information is for MSP purposes only

2320

or

2430

CAS01

Claim adjustment reason code (CO, PR, OA)

CAS02

Claim adjustment reason codes

CAS03

Adjustment amount (amount not paid by the primary)

CAS04

Adjustment quantity

2330B or 2430

DTP01

Primary insurance adjudication date

DTP02

Date time period qualifier

DTP03

Date paid/declined by primary =573

2300 or 2400

CN102

OTAF amount

2430

SVD01

Identification code

SVD02

Primary payer paid amount (line level)

SVD03

Medical procedure identifier

SVD03-1

Service ID qualifier

SVD03-2

Service ID

SVD05

Quantity

2330B

NM101

Entity identifier code

NM102

Entity type code

NM103

Last name or organization

NM108

Identification code qualifier

NM109

Identification code

11c

Insured’s date of birth and gender

2320

SBR04

Other insured’s group name

12

Patient or authorized

2300

CLM08

Condition or response code

CLM09

Release of information code

13

Insured’s or Authorized Person’s Signature

2320

QI03

Assignment of Benefits Indicator

QI06

Release of Information Code

14

Date of Current Illness, Injury or Pregnancy

2300

DTP01

Accident Qualifier = 439

DTP03

Accident Date

DTP01

Date Qualifier = 431

DTP03

Onset of Current Illness or Injury date

2300

or

2400

DTP01

Initial Treatment Qualifier = 454

DTP03

Initial Treatment Date

16

Date patient unable to work in current occupation

2300

DTP01

Disability begin or end qualifier = 360 (Begin date) or 361 (End date)

DTP02

Disability Qualifier

DTP03

Disability begin date

DTP03

Disability end date

17

Name of the Referring or Ordering Physician

2310A or 2420F

NM101

Entity Identifier code = DN

NM102

Entity Type qualifier

NM103

Referring provider last name

NM104

Referring provider first name

NM105

Referring provider middle name

2420E

NM101

Entity Identifier code = DK

NM102

Entity Type qualifier

NM103

Ordering provider last name

NM104

Ordering provider first name

NM105

Ordering provider middle name

17b

NPI Number of Ordering or Referring Provider

2310A or 2420F

NM108

Identifier Code qualifier =XX

NM109

Referring NPI ID

2420E

NM108

Identifier Code qualifier =XX

NM109

Ordering NPI ID

18

Hospitalization Dates related to current services

2300

DTP01

Admission or Discharge qualifier = 435 or 096

DTP03

Admit date

DTP03

Discharge date

19

(cont)

Routine Foot Care

2300

or

2400

DTP01

Date last seen qualifier = 304

DTP02

Date qualifier

DTP03

Date last seen

2310D or 2420D

NM101

Entity identifier code =DQ

NM102

Entity type qualifier

NM103

Last name or organization name

NM104

First name

NM105

Middle name

NM108

Identification code qualifier =XX

NM109

Supervising provider’s NPI

Homebound

2300

CRC01

Homebound code category

CRC02

Condition or response code

CRC03

Condition indicator

Not otherwise classified drugs or Unlisted procedure code (NOC)

2400

SV101-7

Name and dosage for drug codes. Description of service for unlisted procedure code (NOC)

Hearing Aid

2300

or

2400

NTE01

Add = Additional information

NTE02

Testing for Hearing Aid

Extra Modifiers

NTE01

Add = Additional information

NTE02

Extra modifiers

Dental

NTE01

Add – Additional information

NTE02

Specific surgery

Low Osmolar

NTE01

Add = Additional information

NTE02

Name and dosage

Shared Postoperative Care

2300

DTP01

Date / Time Qualifier

DTP02

Date format qualifier

DTP03

Date assumed or relinquished care

19 (cont)

Demonstration ID

2300

REF01

Reference identification qualifier (P4 = Project code)

REF02

Demonstration ID – number

Chiropractor

2300

or

2400

DTP01

Date / Time qualifier

455 = Last X-ray date

DTP02

Date format qualifier

DTP03

Date last seen

Patient refuses to pay

2300

CLM08

Patient refuses to sign

Hematocrit / Hemoglobin / Creatine

2400

DTP01

Hemoglobin or Hematocrit

Serum Creatine

DTP02

Date format qualifier = 738 (Hematocrit/Hemoglobin) 739 (Creatine)

DTP03

Test date performed

MEA01

Measurement reference ID code =TR

MEA02

Measurement qualifier

R1 = Hemoglobin,

R2 = Hematocrit,

R4 = Creatine

MEA03

Measurement values

20

Outside Lab charges

2400

PS101

Reference identification

PS102

Amount of purchased test

21

Diagnosis / Condition

2300

HI01-1

ABK = Principal Diagnosis

HI01-2

Primary diagnosis code

HI02-1 to HI12-1

ABF = Diagnosis code

HI02-2 to HI12-2

2nd through 12th diagnosis code

23

Prior Authorization number

2300

REF01

Reference identification qualifier =LX

REF02 (LX)

IDE number

REF01

(1J)

Facility ID qualifier =1J

REF02

Home Health or Hospice

2300B

or

2400

REF01

Reference identification qualifier =G1

REF02 (G1)

QIO number

2300

or

2400

REF01

Reference identification qualifier =X4

REF02

CLIA Certification number

Ambulance Point of Pickup

2310E

NM101

Entity identifier code =PW

NM102

Entity type qualifier

2310F

NM101

Entity identifier code = 45

NM102

Entity type qualifier

2310E

or

2310F

N301

Address information line 1

N302

Address information line 2

N401

City name

N402

State code

N403

ZIP code

24

National Drug Code

2410

LIN02

Product or Service ID qualifier =N4

LIN03

National Drug code

24a

Dates of Service

2400

DTP01

Date Time Qualifier =472

DTP02

Date format qualifier

D8 = CCYYMMDD

RD8 = CCYYMMDD - CCYYMMDD

DTP03

Date time period

24b

Place of Service

2300

CLM05-1

Place of Service code

CLM05-2

Place of Service qualifier

CLM05-3

Claim frequency type code. 1=initial claim is required.

2400

SV105

Place of Service code

24d

Procedure code / Modifiers

2400

SV101-1

Service ID qualifier =HC

SV101-2

Procedure code

SV101-3

Procedure modifier 1

SV101-4

Procedure modifier 2

SV101-5

Procedure modifier 3

SV101-6

Procedure modifier 4

24e

Diagnosis code reference

2400

SV107-1

Diagnosis code pointer

(A submitter must point to the primary diagnosis for each service line)

SV107-2

SV107-3

SV107-4

24f

Charge Amount

2400

SV102

Line Item charge amount

24g

Days or Units

2400

SV103

Unit or basis for measurement code

(UN = Unit or MJ = Minutes)

SV104

Quantity – Units or Minutes

SV104

24j

Rendering Provider

2310B

or

2420A

NM101

Rendering identifier code =82

NM102

Person

NM103

Last / Organization name

NM104

First name

NM105

Middle name

NM108

Identification code qualifier = XX

NM109

Identification code

25

Provider’s Social Security or Tax Identification number

2010AA

REF01

Reference Identifier qualifier

(EI = Tax ID, SY = Social Security)

REF02

Reference Identification

26

Patient’s Account number

2300

CLM01

Provider Assigned Account number

27

Accept Assignment

2300

CLM07

Medicare Assignment code

A = Assigned

B = Assignment accepted on clinical Lab service only

C = Not assigned

28

Total Charges

2300

CLM02

Total charge amounts

29

Amount paid

2300

AMT01

Amount qualifier code =F5

AMT02

Patient paid amount

31

Signature of physician or supplier and date signed

2300

CLM06

Physician or Supplier signature indicator

32

Service facility location

2310C

or

2420C

NM101

Entity Identifier code =77

NM102

Entity type code

NM103

Facility name

N301

Address

N401,02,
03

City, State and ZIP code

32a

Service facility NPI

2310C

or

2420C

NM108

Identification code qualifier =XX

NM109

Laboratory / Facility qualifier

2400

PS101

Purchased service provider Identifier

2420B

NM101

Identification code qualifier =QB

NM108

Identification code

NM109

Identification code

2300

REF01

Reference Identification qualifier =EW

REF02

Mammogram FDA number

33

Billing Provider’s Information

2010AA

NM101

Entity Identifier code =85

Pay-to-provider

2010AB

NM101

Entity Identifier code =87

Billing Provider’s Information

2010AA or

2010AB

NM102

Entity Type code

NM103

Organization name

N301

Address

N401

City

N402

State

N403

Zip Code

PER03

Communication number qualifier =TE

PER04

Telephone

33a

Billing Provider’s NPI

2010AA or 2010AB

NM101

Entity Identifier code =85

NM108

Identification code qualifier =XX

NM109

Identification number