CMS-1500 (02-12), Health Insurance Claim Form (NUCC Approved) (OMB 0938-1197) Instructions
This form contains 262 fields organized into 16 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Claim Info, Diagnosis, ICD and Prior Auth | ||
| 18. Hospitalization Dates From: (mm) | Text | |
| 18. Hospitalization Dates From: (dd) | Text | |
| 18. Hospitalization Dates From: (yy) | Text | |
| 18. Hospitalization Dates To: (mm) | Text | |
| 18. Hospitalization Dates To: (dd) | Text | |
| 18. Hospitalization Dates To: (yy) | Text | |
| Additional Claim Information | Text |
Enter any extra claim information or NUCC-designated codes that explain or supplement this claim.
|
| 20. Outside Lab? — Yes | Checkbox |
Check this box when the services for this claim were performed by an outside laboratory (i.e., the specimen or testing was sent to a lab not part of the billing provider).
|
| 20. Outside Lab? — No | Checkbox |
Check this box when the services for this claim were not performed by an outside laboratory (i.e., testing was performed by the billing provider and no outside lab was used).
|
| Outside Lab Indicator | Text |
Enter whether an outside laboratory was used for this claim (for example, 'Yes' or 'No').
|
| Outside Lab Charges | Number |
Enter the total dollar amount charged by the outside laboratory for services related to this claim.
|
| ICD Indicator (box 1) | Text |
Enter the first ICD indicator code required by the payer to identify which ICD version applies to the diagnosis codes.
|
| ICD Indicator (box 2) | Text |
Enter the second ICD indicator code required by the payer to identify which ICD version applies to the diagnosis codes.
|
| Diagnosis A | Text |
Enter the ICD diagnosis code for diagnosis A to identify the nature of illness or injury related to this claim.
|
| Diagnosis B | Text |
Enter the ICD diagnosis code for diagnosis B to identify the nature of illness or injury related to this claim.
|
| Diagnosis C | Text |
Enter the ICD diagnosis code for diagnosis C to identify the nature of illness or injury related to this claim.
|
| Diagnosis D | Text |
Enter the ICD diagnosis code for diagnosis D to identify the nature of illness or injury related to this claim.
|
| Diagnosis E | Text |
Enter the ICD diagnosis code for diagnosis E to identify the nature of illness or injury related to this claim.
|
| Diagnosis F | Text |
Enter the ICD diagnosis code for diagnosis F to identify the nature of illness or injury related to this claim.
|
| Diagnosis G | Text |
Enter the ICD diagnosis code for diagnosis G to identify the nature of illness or injury related to this claim.
|
| Diagnosis H | Text |
Enter the ICD diagnosis code for diagnosis H to identify the nature of illness or injury related to this claim.
|
| Diagnosis I | Text |
Enter the ICD diagnosis code for diagnosis I to identify the nature of illness or injury related to this claim.
|
| Diagnosis J | Text |
Enter the ICD diagnosis code for diagnosis J to identify the nature of illness or injury related to this claim.
|
| Diagnosis K | Text |
Enter the ICD diagnosis code for diagnosis K to identify the nature of illness or injury related to this claim.
|
| Diagnosis L | Text |
Enter the ICD diagnosis code for diagnosis L to identify the nature of illness or injury related to this claim.
|
| Resubmission Code | Text |
Enter the resubmission code that indicates whether this claim is an original, a replacement, or a corrected/voided submission.
|
| Original Reference Number | Text |
Enter the original claim reference number when this claim is a resubmission or correction of a previously filed claim.
|
| Prior Authorization Number | Text |
Enter the prior authorization or pre-approval number provided by the payer for the services billed on this claim.
|
| Authorizations & Signatures (Patient / Insured) | ||
| Patient/Authorized Person Signature (Item 12) | Text |
Sign here with the full name of the patient or authorized person to authorize release of medical information and request payment of benefits.
|
| Signature Date (Item 12) | Date |
Enter the date when the patient or authorized person signed the authorization in Item 12.
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| Insured/Authorized Person Signature (Item 13) | Text |
Sign here with the full name of the insured person or their authorized representative to authorize payment to the provider for services described.
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| Date of Current Illness — Month (Item 14) | Date |
Enter the month portion of the date when the current illness, injury, or pregnancy began (Item 14).
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| Date of Current Illness — Day (Item 14) | Date |
Enter the day portion of the date when the current illness, injury, or pregnancy began (Item 14).
|
| Date of Current Illness — Year (Item 14) | Date |
Enter the year portion of the date when the current illness, injury, or pregnancy began (Item 14).
|
| Date of Current Illness — Qualifier (Item 14) | Text |
If applicable, enter the qualifier code or additional note associated with the date of current illness (for example LMP).
|
| Other Date — Month (Item 15) | Date |
Enter the month portion of the 'Other Date' requested in Item 15.
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| Other Date — Day (Item 15) | Date |
Enter the day portion of the 'Other Date' requested in Item 15.
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| Other Date — Year (Item 15) | Date |
Enter the year portion of the 'Other Date' requested in Item 15.
|
| Billing, Payment Totals and Provider Signatures (Tax ID, Account #, Totals, Signatures, Form IDs) | ||
| Federal Tax I.D. Number | Text |
Enter the provider's federal tax identification number (EIN or SSN) used for billing this claim.
|
| 25. Federal Tax I.D. Number — SSN | Checkbox |
Check this box when the Federal Tax I.D. number entered in item 25 is an individual's Social Security Number (SSN).
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| 25. Federal Tax I.D. Number — EIN | Checkbox |
Check this box when the Federal Tax I.D. number entered in item 25 is an employer identification number (EIN).
|
| Patient's Account Number | Text |
Enter the provider's or payer's internal account number for this patient/claim.
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| 27. Accept Assignment — YES | Checkbox |
Check this box to indicate the provider accepts assignment of insurance benefits for the billed services.
|
| 27. Accept Assignment — NO | Checkbox |
Check this box to indicate the provider does not accept assignment of insurance benefits for the billed services.
|
| Accept Assignment | Text |
Enter whether the provider accepts assignment of benefits for this claim (for example, 'YES' or 'NO').
|
| Total Charge | Number |
Enter the total charge amount for all services billed on this claim.
|
| Amount Paid | Number |
Enter any amount already paid toward this claim by the patient or another payer.
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| Reserved for NUCC Use (1) | Text |
Enter any NUCC-reserved code or value required by your payer, or leave blank if not applicable.
|
| Reserved for NUCC Use (2) | Text |
Enter any additional NUCC-reserved information required by your payer, or leave blank if not applicable.
|
| Reserved for NUCC Use (3) | Text |
Enter any further NUCC-reserved codes or values as required by your payer, or leave blank if not applicable.
|
| Physician/Supplier Signature | Text |
Enter the signature (printed name or electronic signature) of the physician or supplier certifying the information on this claim.
|
| Signature Date | Date |
Enter the date the physician or supplier signed this claim.
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| Service Facility Location Name | Text |
Enter the name of the facility or location where the services were performed.
|
| Service Facility Address | Text |
Enter the street address (and optionally city/state/ZIP) of the service facility where services were provided.
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| Service Facility NPI | Text |
Enter the service facility's National Provider Identifier (NPI) number.
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| Billing Provider Other ID | Text |
Enter any secondary billing provider identifier required by the payer (other than tax ID or NPI).
|
| Billing Provider Phone Number | Text |
Enter the billing provider's daytime telephone number for contact about this claim.
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| Billing Provider Name and Address | Text |
Enter the billing provider's name and mailing address responsible for this claim.
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| Billing Provider NPI | Text |
Enter the billing provider's National Provider Identifier (NPI) number.
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| Rendering Provider ID / Other ID | Text |
Enter the rendering provider's identifier or other provider ID required by the payer (for example a state license or internal provider number).
|
| Condition / Accident / Claim Details | ||
| 10a. Employment? — Yes | Checkbox |
Check this box when the patient's condition is related to current or previous employment.
|
| 10a. Employment? — No | Checkbox |
Check this box when the patient's condition is not related to employment.
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| 10b. Auto Accident? — Yes | Checkbox |
Check this box when the patient's condition resulted from an auto (motor vehicle) accident.
|
| 10b. Auto Accident? — No | Checkbox |
Check this box when the patient's condition did not result from an auto (motor vehicle) accident.
|
| Accident Place (State) | Text |
Enter the U.S. state (abbreviation or full name) where the auto accident occurred.
|
| 10c. Other Accident? — Yes | Checkbox |
Check this box when the patient's condition resulted from an accident other than an auto accident.
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| 10c. Other Accident? — No | Checkbox |
Check this box when the patient's condition did not result from any other accident.
|
| Claim Codes (10d) | Text |
Enter the claim code or codes designated by the NUCC for this claim.
|
| Insured's Policy/Group or FECA Number | Text |
Provide the insured's policy or group number or FECA number associated with the coverage shown.
|
| Insured's Date of Birth — Month | Date |
Enter the insured person's month of birth.
|
| Insured's Date of Birth — Day | Date |
Enter the insured person's day of birth.
|
| Insured's Date of Birth — Year | Date |
Enter the insured person's year of birth.
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| 11a. Insured's Sex — M | Checkbox |
Check this box if the insured person's sex is Male.
|
| 11a. Insured's Sex — F | Checkbox |
Check this box if the insured person's sex is Female.
|
| Other Claim ID — Segment 1 | Text |
Enter the first segment or prefix of the other claim identification number as designated by NUCC.
|
| Other Claim ID — Segment 2 | Text |
Enter the remaining portion of the other claim identification number as designated by NUCC.
|
| Insurance Plan or Program Name | Text |
Enter the full name of the insured's insurance plan or program.
|
| Is there another health benefit plan? — Yes | Checkbox |
Check this box if there is another health benefit plan in addition to the one shown on this form.
|
| Is there another health benefit plan? — No | Checkbox |
Check this box if there is no other health benefit plan in addition to the one shown on this form.
|
| Dates, Employer, Referral and Source of Admission | ||
| Date of current illness/injury/pregnancy (Item 14) | Date |
Enter the date the current illness, injury, or pregnancy began as reported in item 14.
|
| Other date (Item 15) | Date |
Enter the other relevant date requested in item 15 (for example a secondary or related event date).
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| Patient unable to work — FROM (Item 16 start) | Date |
Enter the start date of the period the patient was unable to work in their current occupation (item 16 FROM).
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| Patient unable to work — TO (Item 16 end) | Date |
Enter the end date of the period the patient was unable to work in their current occupation (item 16 TO).
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| Hospitalization dates — FROM (Item 18 start) | Date |
Enter the admission (start) date of hospitalization related to the current services (item 18 FROM).
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| Hospitalization dates — TO (Item 18 end) | Date |
Enter the discharge (end) date of hospitalization related to the current services (item 18 TO).
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| 16. Dates Unable to Work: To (yy) | Text | |
| Referring provider or other source — name (Item 17) | Text |
Enter the referring provider's or other source's full name (Last, First, Middle initial) for item 17.
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| Referring provider or other source — additional info | Text |
Enter any additional identifying information for the referring provider or source (for example credentials, facility/organization name, or other clarifying text).
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| Referring provider ID — part 1 (Item 17a) | Text |
Enter the first portion of the referring provider's identification number or other ID required in item 17a.
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| Referring provider ID — part 2 (Item 17a continuation) | Text |
Enter the continuation or secondary portion of the referring provider's identification number for item 17a, if applicable.
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| Referring provider NPI (Item 17b) | Number |
Enter the referring provider's National Provider Identifier (NPI) number for item 17b.
|
| Form Header (PICA and Insurance Type) | ||
| PICA / Program Indicator | Text |
Enter the PICA or program indicator code that identifies the specific insurance program for this claim (e.g., Medicare, Medicaid program code).
|
| Carrier Name or Code | Text |
Enter the name or identifying code of the insurance carrier responsible for this claim as shown on the form. Fill only if 'MEDICARE (Medicare#)', 'MEDICAID (Medicaid#)', 'TRICARE (ID#/DoD#)', 'CHAMPVA (Member ID#)', 'GROUP HEALTH PLAN (ID#)', 'FECA / BLK LUNG (ID#)', 'OTHER (ID#)' is 'Yes' (any).
Depends on:
MEDICARE (Medicare#), MEDICAID (Medicaid#), TRICARE (ID#/DoD#), CHAMPVA (Member ID#), GROUP HEALTH PLAN (ID#), FECA / BLK LUNG (ID#), OTHER (ID#)
|
| MEDICARE (Medicare#) | Checkbox |
Check this box when the patient’s primary coverage is Medicare.
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| MEDICAID (Medicaid#) | Checkbox |
Check this box when the patient is enrolled in Medicaid.
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| TRICARE (ID#/DoD#) | Checkbox |
Check this box when the patient’s coverage is TRICARE (military health benefits).
|
| CHAMPVA (Member ID#) | Checkbox |
Check this box when the patient is covered by CHAMPVA.
|
| GROUP HEALTH PLAN (ID#) | Checkbox |
Check this box when the patient’s insurance is a group or employer-sponsored health plan.
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| FECA / BLK LUNG (ID#) | Checkbox |
Check this box when the patient’s benefits are under FECA (Federal Employees' Compensation Act) or Black Lung programs.
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| OTHER (ID#) | Checkbox |
Check this box when the patient’s insurance type is not listed above and specify the program in the provided space.
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| Insured's ID Number (Item 1a) | Text |
Enter the insured member's identification number exactly as it appears on their insurance card or policy for Item 1a.
|
| General | ||
| PICA1 (top left) | Text | |
| PICA2 (top left) | Text | |
| PICA3 (top left) | Text | |
| PICA1 (top right) | Text | |
| PICA2 (top right) | Text | |
| PICA3 (top right) | Text | |
| Insured / Relationship / Address Block | ||
| Self | Checkbox |
Check this box if the patient is the insured person (self).
|
| Spouse | Checkbox |
Check this box if the patient is the insured person's spouse.
|
| Child | Checkbox |
Check this box if the patient is the insured person's child.
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| Other | Checkbox |
Check this box if the patient's relationship to the insured is not listed (other).
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| Insured's Address | Text |
Enter the insured person's street address, including house number, street name and apartment or suite number if applicable.
|
| Insured's City | Text |
Enter the city of the insured person's mailing address.
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| Insured's State | Text |
Enter the two-letter state or province code for the insured person's address.
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| Insured's ZIP Code | Number |
Enter the insured person's ZIP or postal code for their address.
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| Insured Telephone Area Code | Text |
Enter the area code portion of the insured person's telephone number.
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| Insured Telephone Number | Number |
Enter the insured person's telephone number excluding the area code.
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| Reserved for NUCC Use | Text |
Enter any codes or information required by NUCC in the reserved field as instructed by the payer or form guidance.
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| Other Insured's Name | Text |
Enter the other insured person's full name (last name, first name, middle initial) when another individual is covered. Fill only if 'Is there another health benefit plan? — Yes' is 'Yes'.
Depends on:
Is there another health benefit plan? — Yes
|
| Other Insured's Policy/Group Number | Text |
Enter the policy or group number for the other insured as shown on their insurance card or documents. Fill only if 'Is there another health benefit plan? — Yes' is 'Yes'.
Depends on:
Is there another health benefit plan? — Yes
|
| Reserved for NUCC Use (b) | Text |
Enter any additional codes or payer-required information for NUCC use in this reserved field.
|
| Reserved for NUCC Use (c) | Text |
Enter any supplemental NUCC or payer-specific data required in this reserved field.
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| Insurance Plan or Program Name | Text |
Enter the name of the insurance plan or program that covers the other insured or patient. Fill only if 'Is there another health benefit plan? — Yes' is 'Yes'.
Depends on:
Is there another health benefit plan? — Yes
|
| Patient Identification (Name, DOB, Sex, Address, Contact) | ||
| Patient Name | Text |
Enter the patient’s full name in the order Last Name, First Name, Middle Initial as shown on the form.
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| Patient Birth Month | Date |
Provide the month portion of the patient’s birth date (the month component of the birth date).
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| Patient Birth Day | Date |
Provide the day portion of the patient’s birth date (the day component of the birth date).
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| Patient Birth Year | Date |
Provide the year portion of the patient’s birth date (the year component of the birth date).
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| Patient Sex - Male | Checkbox |
Check this box when the patient's sex is male.
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| Patient Sex - Female | Checkbox |
Check this box when the patient's sex is female.
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| Insured's Name | Text |
Enter the insured person’s full name in the order Last Name, First Name, Middle Initial as printed on the policy.
|
| Patient Street Address | Text |
Enter the patient’s street address and number (house or building number and street name).
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| Patient City | Text |
Enter the city of the patient’s mailing or residential address.
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| Patient State | Text |
Enter the U.S. state or province for the patient’s address (commonly the two-letter state abbreviation).
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| Patient ZIP Code | Text |
Enter the postal ZIP code for the patient’s address.
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| Telephone Area Code | Text |
Enter the area code portion of the patient’s daytime telephone number.
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| Telephone Number | Text |
Enter the local part of the patient’s daytime telephone number (the exchange and line number).
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| Physician / Supplier (Provider IDs, NPI, State Lic #, Additional Service Fields) | ||
| Service Line 1 NPI | Number |
Enter the provider's National Provider Identifier (NPI) associated with the first service line.
|
| Service Line 2 NPI | Number |
Enter the provider's National Provider Identifier (NPI) associated with the second service line.
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| Service Line 3 NPI | Number |
Enter the provider's National Provider Identifier (NPI) associated with the third service line.
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| Service Line 4 NPI | Number |
Enter the provider's National Provider Identifier (NPI) associated with the fourth service line.
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| Service Line 5 NPI | Number |
Enter the provider's National Provider Identifier (NPI) associated with the fifth service line.
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| Service Line 6 NPI | Number |
Enter the provider's National Provider Identifier (NPI) associated with the sixth service line.
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| Service Line 7 NPI | Number |
Enter the provider's National Provider Identifier (NPI) associated with the seventh service line.
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| Service Line 8 NPI | Number |
Enter the provider's National Provider Identifier (NPI) associated with the eighth service line.
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| Service Line 9 NPI | Number |
Enter the provider's National Provider Identifier (NPI) associated with the ninth service line.
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| Rendering Provider ID # | Text |
Enter the rendering (performing) provider's identification number as assigned by the payer or state licensing authority.
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| Billing/Pay-to Provider NPI | Number |
Enter the billing or pay-to provider's National Provider Identifier (NPI).
|
| Additional Provider ID / NUCC Use | Text |
Enter any additional provider identification number or code (such as state license, legacy ID, or NUCC-designated value) required by the payer.
|
| Service Line Row 1 (24A-J / CPT / Charges / Units / Rendering Provider) | ||
| Row 1 — 24A From Date (Month) | Date |
Enter the service line Row 1 start date (24A) for the dates of service.
|
| Row 1 — 24A From Date (Day) | Date |
Enter the service line Row 1 start date (24A) for the dates of service.
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| Row 1 — 24A From Date (Year) | Date |
Enter the service line Row 1 start date (24A) for the dates of service.
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| Row 1 — 24A To Date (Month) | Date |
Enter the service line Row 1 end date (24A) for the dates of service.
|
| Row 1 — 24A To Date (Day) | Date |
Enter the service line Row 1 end date (24A) for the dates of service.
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| Row 1 — 24A To Date (Year) | Date |
Enter the service line Row 1 end date (24A) for the dates of service.
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| Row 1 — 24B Place of Service | Text |
Enter the place-of-service code for Row 1 (24B) that indicates where the service was provided.
|
| Row 1 — 24C EMG Indicator | Text |
Enter any emergency indicator or special condition code for Row 1 (24C) if applicable.
|
| Row 1 — 24D CPT/HCPCS Procedure Code | Text |
Enter the CPT or HCPCS procedure code performed for Row 1 (24D).
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| Row 1 — 24D Modifier 1 | Text |
Enter the first procedure modifier associated with the CPT/HCPCS code for Row 1 (24D), if applicable.
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| Row 1 — 24D Modifier 2 | Text |
Enter the second procedure modifier associated with the CPT/HCPCS code for Row 1 (24D), if applicable.
|
| Row 1 — 24D Modifier 3 | Text |
Enter the third procedure modifier associated with the CPT/HCPCS code for Row 1 (24D), if applicable.
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| Row 1 — 24D Modifier 4 | Text |
Enter the fourth procedure modifier associated with the CPT/HCPCS code for Row 1 (24D), if applicable.
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| Row 1 — 24E Diagnosis Pointer | Text |
Enter the diagnosis pointer letter(s) (referencing the diagnosis lines) that apply to the service on Row 1 (24E).
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| Row 1 — 24F Charges | Number |
Enter the total charge amount for the service line on Row 1 (24F).
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| Row 1 — 24G Days or Units | Text |
Enter the number of units or days billed for the service on Row 1 (24G).
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| Row 1 — 24H EPSDT / Family Plan | Text |
Enter the EPSDT/family planning indicator for Row 1 (24H) if the service is related to those programs.
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| Row 1 — 24I Provider ID Qualifier | Text |
Enter the identifier qualifier code for the rendering provider ID entered on Row 1 (24I/24J), such as the qualifier type.
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| Row 1 — 24J Rendering Provider ID Qualifier (Label) | Text |
Enter the rendering provider ID qualifier label for Row 1 (24J) indicating the type of identifier being provided.
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| Row 1 — 24J Rendering Provider ID # | Number |
Enter the rendering provider's identifier for Row 1 (24J), for example the provider's NPI or other assigned ID.
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| Service Line Row 2 (24A-J / CPT / Charges / Units / Rendering Provider) | ||
| 24j. (1) Renderin Provider ID # 2 | Text | |
| Service Line 2 — From (month) | Date |
Enter the month component of the service line 2 start date (the FROM date) for this service line.
|
| Service Line 2 — From (day) | Date |
Enter the day component of the service line 2 start date (the FROM date) for this service line.
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| Service Line 2 — From (year) | Date |
Enter the year component of the service line 2 start date (the FROM date) for this service line.
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| Service Line 2 — To (month) | Date |
Enter the month component of the service line 2 end date (the TO date) for this service line.
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| Service Line 2 — To (day) | Date |
Enter the day component of the service line 2 end date (the TO date) for this service line.
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| Service Line 2 — To (year) | Date |
Enter the year component of the service line 2 end date (the TO date) for this service line.
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| Service Line 2 — Place of Service (POS) | Text |
Enter the Place of Service code for service line 2 as shown on the claim (e.g., the two-digit POS code).
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| Service Line 2 — Emergency indicator (EMG) | Text |
Enter the emergency indicator for service line 2 (enter the appropriate short code or letter used on the form to indicate emergency services).
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| Service Line 2 — CPT/HCPCS code character 1 | Text |
Enter the first character of the CPT/HCPCS procedure code for service line 2.
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| Service Line 2 — CPT/HCPCS code character 2 | Text |
Enter the second character of the CPT/HCPCS procedure code for service line 2.
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| Service Line 2 — CPT/HCPCS code character 3 | Text |
Enter the third character of the CPT/HCPCS procedure code for service line 2.
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| Service Line 2 — CPT/HCPCS code character 4 | Text |
Enter the fourth character of the CPT/HCPCS procedure code for service line 2.
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| Service Line 2 — CPT/HCPCS code character 5 | Text |
Enter the fifth character of the CPT/HCPCS procedure code for service line 2.
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| Service Line 2 — Modifier 1 | Text |
Enter the first modifier associated with the CPT/HCPCS procedure on service line 2, if applicable.
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| Service Line 2 — Modifier 2 | Text |
Enter the second modifier associated with the CPT/HCPCS procedure on service line 2, if applicable.
|
| Service Line 2 — Diagnosis Pointer | Text |
Enter the diagnosis pointer(s) (letter(s) referencing the diagnosis in the diagnosis section) for service line 2.
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| Service Line 2 — Charges | Number |
Enter the total charge amount for the services billed on service line 2.
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| Service Line 2 — Days/Units | Text |
Enter the number of units or days billed for the service on service line 2.
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| Service Line 2 — Rendering Provider ID (NPI) | Number |
Enter the rendering provider identification number (NPI) for the provider who performed or ordered the service on service line 2.
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| Service Line Row 3 (24A-J / CPT / Charges / Units / Rendering Provider) | ||
| 24j. (2) Renderin Provider ID # 1 | Text | |
| 24j. (2) Renderin Provider ID # 2 | Text | |
| Row 3: Service Date — From (24A) | Date |
Enter the service start date for this service line.
|
| Row 3: Service Date — To (24A) | Date |
Enter the service end date for this service line.
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| Row 3: Place of Service (24B) | Text |
Enter the place-of-service code or description indicating where the service was provided.
|
| Row 3: Emergency Indicator (24C) | Text |
Indicate whether the service was an emergency by providing the appropriate emergency indicator or code if applicable.
|
| Row 3: CPT/HCPCS Code — Character 1 (24D) | Text |
Enter the first character of the CPT or HCPCS procedure code for this service line.
|
| Row 3: CPT/HCPCS Code — Character 2 (24D) | Text |
Enter the second character of the CPT or HCPCS procedure code for this service line.
|
| Row 3: CPT/HCPCS Code — Character 3 (24D) | Text |
Enter the third character of the CPT or HCPCS procedure code for this service line.
|
| Row 3: CPT/HCPCS Code — Character 4 (24D) | Text |
Enter the fourth character of the CPT or HCPCS procedure code for this service line.
|
| Row 3: CPT/HCPCS Code — Character 5 (24D) | Text |
Enter the fifth character of the CPT or HCPCS procedure code for this service line.
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| Row 3: Modifier 1 (24D) | Text |
Enter the first CPT/HCPCS modifier associated with the procedure, if any.
|
| Row 3: Modifier 2 (24D) | Text |
Enter the second CPT/HCPCS modifier associated with the procedure, if any.
|
| Row 3: Modifier 3 (24D) | Text |
Enter the third CPT/HCPCS modifier associated with the procedure, if any.
|
| Row 3: Modifier 4 (24D) | Text |
Enter the fourth CPT/HCPCS modifier associated with the procedure, if any.
|
| Row 3: Diagnosis Pointer (24E) | Text |
Enter the diagnosis pointer letter(s) that link this service line to the appropriate diagnosis in Item 21.
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| Row 3: Charge Amount (24F) | Number |
Enter the total charge amount billed for this service line.
|
| Row 3: Days or Units (24G) | Text |
Enter the number of units or days billed for this service line.
|
| Row 3: ID Qualifier / Rendering Provider ID (24I / 24J) | Text |
Enter the identification qualifier code and the rendering provider identifier (for example the provider NPI or other ID as indicated) for this service line.
|
| Service Line Row 4 (24A-J / CPT / Charges / Units / Rendering Provider) | ||
| 24h. (3) EPSDT Family Plan | Text | |
| 24i. (3) ID Qual | Text | |
| 24j. (3) Renderin Provider ID #1 | Text | |
| Service Line 4 — Rendering Provider ID (NPI) | Number |
Enter the rendering provider identifier (NPI) associated with the services billed on service line 4.
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| Service Line 4 — Date of Service (From) - MM | Date |
Enter the service line 4 start date (the 'from' date) for the billed service.
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| Service Line 4 — Date of Service (From) - DD | Date |
Enter the service line 4 start date (the 'from' date) for the billed service.
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| Service Line 4 — Date of Service (From) - YY | Date |
Enter the service line 4 start date (the 'from' date) for the billed service.
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| Service Line 4 — Date of Service (To) - MM | Date |
Enter the service line 4 end date (the 'to' date) for the billed service.
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| Service Line 4 — Date of Service (To) - DD | Date |
Enter the service line 4 end date (the 'to' date) for the billed service.
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| Service Line 4 — Date of Service (To) - YY | Date |
Enter the service line 4 end date (the 'to' date) for the billed service.
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| Service Line 4 — Place of Service (POS) | Text |
Enter the Place of Service code that indicates where the service was performed for service line 4.
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| Service Line 4 — EMG / Special Indicator | Text |
Enter any emergency or other special service indicator applicable to this service line (e.g., emergency flag).
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| Service Line 4 — CPT/HCPCS Procedure Code | Text |
Enter the CPT or HCPCS procedure code that describes the service provided on service line 4.
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| Service Line 4 — Modifier(s) | Text |
Enter any CPT/HCPCS modifier code(s) that apply to the procedure on service line 4.
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| Service Line 4 — Diagnosis Pointer | Text |
Enter the diagnosis pointer letter(s) (A–L) that link this service line to the applicable diagnosis(es).
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| Service Line 4 — Charges | Number |
Enter the total charge amount for the services billed on service line 4.
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| Service Line 4 — Days or Units | Text |
Enter the number of days or units of service provided for service line 4.
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| Service Line 4 — Rendering Provider ID Qualifier | Text |
Enter the qualifier that identifies the type of provider ID supplied in the rendering provider ID field for service line 4.
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| Service Line Row 5 (24A-J / CPT / Charges / Units / Rendering Provider) | ||
| 24f. (4) Charges1 | Text | |
| 24f. (4) Charges2 | Text | |
| 24g. (4) Days or Units | Text | |
| 24h. (4) EPSDT Family Plan | Text | |
| 24i. (4) ID Qual | Text | |
| 24j. (4) Renderin Provider ID #1 | Text | |
| 24j. (4) Renderin Provider ID #2 | Text | |
| Service Line Row 5 - Date of Service (From) | Date |
Enter the starting date of the service for this service line.
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| Service Line Row 5 - Place of Service (POS) | Text |
Enter the two‑character place of service code that identifies where the service was provided.
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| Service Line Row 5 - EMG Indicator | Text |
Enter the emergency indicator or code for this service line if applicable.
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| Service Line Row 5 - Procedure Code (CPT/HCPCS) | Text |
Enter the CPT or HCPCS procedure code that describes the service performed on this line.
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| Service Line Row 5 - Modifier(s) | Text |
Enter any CPT/HCPCS modifier(s) associated with the procedure code for this service line.
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| Service Line Row 5 - Diagnosis Pointer | Text |
Enter the diagnosis pointer (reference letter or number) tying this service line to the applicable diagnosis listed elsewhere on the form.
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| Service Line Row 5 - Charges | Number |
Enter the total charge amount billed for this service line.
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| Service Line Row 5 - Days or Units | Text |
Enter the number of service days or units provided for this service line.
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| Service Line Row 5 - EPSDT / Family Plan | Text |
Enter any EPSDT or family‑plan indicator applicable to this service line or leave blank if not applicable.
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| Service Line Row 5 - ID Qualifier | Text |
Enter the identifier qualifier that indicates the type of provider ID used in the rendering provider ID field (for example, '1' for NPI or other qualifier).
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| Service Line Row 5 - Rendering Provider ID Number | Number |
Enter the rendering provider's identification number (for example, NPI) associated with this service line.
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| Service Line Row 6 (24A-J / CPT / Charges / Units / Rendering Provider) | ||
| Service Line 6 - Procedure Code (CPT/HCPCS) | Text |
Enter the CPT or HCPCS procedure code performed for service line 6.
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| Service Line 6 - Modifier 1 | Text |
Enter the first procedure modifier (if any) associated with the CPT/HCPCS code on service line 6.
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| Service Line 6 - Modifier 2 | Text |
Enter the second procedure modifier (if any) associated with the CPT/HCPCS code on service line 6.
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| Service Line 6 - Diagnosis Pointer | Text |
Enter the diagnosis pointer letter(s) (A–L) that relate this procedure to the diagnosis on service line 6.
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| Service Line 6 - Charges | Number |
Enter the total charge amount for this service line (dollars and cents) as billed.
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| Service Line 6 - Days or Units | Text |
Enter the number of days or units provided for the procedure on service line 6.
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| Service Line 6 - EPSDT/Family Planning Indicator | Text |
Enter any applicable EPSDT/Family Planning/other special program indicator for this service line, if required.
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| Service Line 6 - Rendering Provider NPI | Number |
Enter the 10‑digit NPI of the rendering provider who performed the service on line 6.
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| Service Line 6 - Rendering Provider ID Qualifier | Text |
Enter the qualifier that identifies the type of identifier supplied for the rendering provider (for example, '1G' or other qualifier).
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| Service Line 6 - Rendering Provider ID Number | Text |
Enter the rendering provider's secondary identifier (the provider ID number) as required by the payer.
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| Service Line 6 - Date of Service From | Date |
Enter the starting date of service (FROM) for service line 6.
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| Service Line 6 - Date of Service To | Date |
Enter the ending date of service (TO) for service line 6 if different from the FROM date; otherwise repeat the same date.
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| Service Line 6 - Place of Service | Text |
Enter the two‑digit place of service code that identifies where the service was rendered for line 6.
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| Service Line 6 - Emergency Indicator (EMG) | Text |
Enter the emergency indicator code (if applicable) to show whether the service on line 6 was provided due to an emergency.
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| Service Line 6 - Procedure Code (continued) 1 | Text |
Enter additional characters of the procedure code or any overflow/continuation characters for the CPT/HCPCS code on line 6, if required.
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| Service Line 6 - Procedure Code (continued) 2 | Text |
Enter further continuation characters for the CPT/HCPCS procedure code on service line 6, if required.
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| Service Line 6 - Procedure Code (continued) 3 | Text |
Enter any remaining continuation characters for the procedure code or supplemental procedure identifier for line 6.
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| Service Line 6 - Procedure Code (continued) 4 | Text |
Enter any additional continuation characters or an extended procedure identifier for service line 6, if needed.
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| Service Line 6 - Procedure Code (continued) 5 / Additional Flag | Text |
Enter a final continuation character or any additional small-code flag used to complete the procedure identification for line 6.
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