CMS-1500 (02-12), Health Insurance Claim Form (NUCC Approved) (OMB 0938-1197) Instructions
This form contains 262 fields organized into 33 sections, giving it a Form Complexity Index of 73/100 (complex). Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Claim Info & Outside Lab (Items 19-20) | ||
| Additional Claim Information | Text |
Enter any additional claim information or remarks designated by NUCC that apply to this claim.
|
| Outside Lab: Yes | Checkbox |
Check this box if the lab work for this claim was performed by an outside (non-office) laboratory.
|
| Outside Lab: No | Checkbox |
Check this box if the lab work for this claim was not performed by an outside laboratory.
|
| Outside Lab Indicator | Text |
Indicate whether the services were performed by an outside laboratory (e.g., enter Yes or No).
|
| Outside Lab Charges | Number |
Enter the total charges amount for services performed by an outside laboratory.
|
| Another Health Benefit Plan (11d) | ||
| Yes | Checkbox |
Check this box if the patient is covered by another health benefit plan in addition to the plan listed on this claim.
|
| No | Checkbox |
Check this box if the patient is not covered by any other health benefit plan besides the plan listed on this claim.
|
| Billing Provider Info & Phone (Item 33) | ||
| Billing Provider Phone Area Code | Text |
Enter the area code portion of the billing provider’s phone number.
|
| Billing Provider Phone Number | Text |
Enter the remaining digits of the billing provider’s phone number.
|
| Billing Provider Name and Address | Text |
Enter the billing provider’s name and mailing address (and other identifying details as needed) as shown in Item 33.
|
| Billing Provider NPI (33a) | Text |
Enter the billing provider’s National Provider Identifier (NPI).
|
| Billing Provider Other ID (33b) | Text |
Enter the billing provider’s other identifier (if applicable) as required by the payer.
|
| Claim Codes (10d) | ||
| Claim Codes (10d) | Text |
Enter any applicable claim codes for this claim as designated by the NUCC.
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| Diagnosis Information (Item 21) | ||
| ICD Indicator | Text |
Enter the ICD code set indicator that applies to the diagnosis codes listed (as required by the form).
|
| Diagnosis Code A | Text |
Enter the primary diagnosis code (A) describing the patient’s illness or injury.
|
| Diagnosis Code B | Text |
Enter diagnosis code B describing the patient’s illness or injury.
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| Diagnosis Code C | Text |
Enter diagnosis code C describing the patient’s illness or injury.
|
| Diagnosis Code D | Text |
Enter diagnosis code D describing the patient’s illness or injury.
|
| Diagnosis Code E | Text |
Enter diagnosis code E describing the patient’s illness or injury.
|
| Diagnosis Code F | Text |
Enter diagnosis code F describing the patient’s illness or injury.
|
| Diagnosis Code G | Text |
Enter diagnosis code G describing the patient’s illness or injury.
|
| Diagnosis Code H | Text |
Enter diagnosis code H describing the patient’s illness or injury.
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| Diagnosis Code I | Text |
Enter diagnosis code I describing the patient’s illness or injury.
|
| Diagnosis Code J | Text |
Enter diagnosis code J describing the patient’s illness or injury.
|
| Diagnosis Code K | Text |
Enter diagnosis code K describing the patient’s illness or injury.
|
| Diagnosis Code L | Text |
Enter diagnosis code L describing the patient’s illness or injury.
|
| Diagnosis Code M | Text |
Enter an additional diagnosis code (M) describing the patient’s illness or injury, if applicable.
|
| Fifth Service Line (Item 24 - Row 5) | ||
| From Date of Service - Month | Date |
Enter the month portion of the start date for this fifth service line.
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| From Date of Service - Day | Text |
Enter the day portion of the start date for this fifth service line.
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| From Date of Service - Year | Text |
Enter the year portion of the start date for this fifth service line.
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| To Date of Service - Month | Text |
Enter the month portion of the end date for this fifth service line (if different from the from date).
|
| To Date of Service - Day | Text |
Enter the day portion of the end date for this fifth service line (if different from the from date).
|
| To Date of Service - Year | Text |
Enter the year portion of the end date for this fifth service line (if different from the from date).
|
| Place of Service | Number |
Enter the place of service code for where the service was provided on this fifth service line.
|
| Emergency Indicator (EMG) | Text |
Enter the emergency indicator value for this fifth service line, if applicable.
|
| Procedure/Service Code (CPT/HCPCS) | Text |
Enter the CPT/HCPCS procedure or service code for this fifth service line.
|
| Modifier 1 | Text |
Enter the first procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.
|
| Modifier 2 | Number |
Enter the second procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.
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| Modifier 3 | Text |
Enter the third procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.
|
| Modifier 4 | Text |
Enter the fourth procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.
|
| Diagnosis Pointer | Text |
Enter the diagnosis pointer(s) (letters/numbers that reference the diagnoses listed in Item 21) that apply to this fifth service line.
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| Line Item Charges | Number |
Enter the charge amount billed for this fifth service line.
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| Days or Units | Number |
Enter the number of days or units for the service billed on this fifth service line.
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| EPSDT Indicator | Text |
Enter the EPSDT indicator value for this fifth service line, if applicable.
|
| Family Plan Indicator | Text |
Enter the family plan indicator value for this fifth service line, if applicable.
|
| Rendering Provider ID Qualifier | Number |
Enter the qualifier that identifies the type of rendering provider ID reported for this fifth service line.
|
| Rendering Provider ID (Non-NPI) | Text |
Enter the rendering provider's non-NPI identifier for this fifth service line, if required.
|
| Rendering Provider NPI | Text |
Enter the rendering provider's National Provider Identifier (NPI) for this fifth service line.
|
| First Service Line (Item 24 - Row 1) | ||
| Service From Month | Date |
Enter the month of the start date of service for this service line.
|
| Service From Day | Date |
Enter the day of the start date of service for this service line.
|
| Service From Year | Date |
Enter the year of the start date of service for this service line.
|
| Service To Month | Date |
Enter the month of the end date of service for this service line, if applicable.
|
| Service To Day | Date |
Enter the day of the end date of service for this service line, if applicable.
|
| Service To Year | Date |
Enter the year of the end date of service for this service line, if applicable.
|
| Place of Service | Text |
Enter the place of service code that indicates where the service was provided.
|
| Emergency Indicator | Text |
Enter the emergency indicator value for this service line, if required.
|
| Procedure Code (CPT/HCPCS) | Text |
Enter the CPT or HCPCS procedure code for the service provided.
|
| Modifier 1 | Text |
Enter the first procedure modifier, if applicable.
|
| Modifier 2 | Text |
Enter the second procedure modifier, if applicable.
|
| Modifier 3 | Text |
Enter the third procedure modifier, if applicable.
|
| Modifier 4 | Text |
Enter the fourth procedure modifier, if applicable.
|
| Diagnosis Pointer | Text |
Enter the diagnosis code reference(s) (pointer) that apply to this procedure.
|
| Line Item Charges | Number |
Enter the total charge amount for this service line.
|
| Days or Units | Number |
Enter the number of days or units billed for this service line.
|
| EPSDT/Family Plan | Text |
Enter the EPSDT or family planning indicator/code, if applicable.
|
| Rendering Provider ID Qualifier | Text |
Enter the qualifier that identifies the type of non-NPI rendering provider identifier being reported.
|
| Rendering Provider NPI | Text |
Enter the rendering provider’s National Provider Identifier (NPI) for this service line.
|
| 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.
|
| Rendering Provider Other ID | Text |
Enter the rendering provider’s non-NPI identifier for this service line, if applicable.
|
| Fourth Service Line (Item 24 - Row 4) | ||
| Service Line 4 From Date (MM) | Date |
Enter the month of the start date for the service period on this service line.
|
| Service Line 4 From Date (DD) | Date |
Enter the day of the start date for the service period on this service line.
|
| Service Line 4 From Date (YY) | Date |
Enter the two-digit year of the start date for the service period on this service line.
|
| Service Line 4 To Date (MM) | Date |
Enter the month of the end date for the service period on this service line.
|
| Service Line 4 To Date (DD) | Date |
Enter the day of the end date for the service period on this service line.
|
| Service Line 4 To Date (YY) | Date |
Enter the two-digit year of the end date for the service period on this service line.
|
| Service Line 4 Place of Service | Text |
Enter the place of service code that describes where the service was provided for this service line.
|
| Service Line 4 Emergency Indicator | Text |
Enter the emergency indicator value for this service line, if applicable.
|
| Service Line 4 Procedure Code (CPT/HCPCS) | Text |
Enter the CPT/HCPCS procedure code for the service or item billed on this service line.
|
| Service Line 4 Modifier 1 | Text |
Enter the first procedure modifier associated with the billed procedure code on this service line, if any.
|
| Service Line 4 Modifier 2 | Text |
Enter the second procedure modifier associated with the billed procedure code on this service line, if any.
|
| Service Line 4 Modifier 3 | Number |
Enter the third procedure modifier associated with the billed procedure code on this service line, if any.
|
| Service Line 4 Modifier 4 | Text |
Enter the fourth procedure modifier associated with the billed procedure code on this service line, if any.
|
| Service Line 4 Diagnosis Pointer | Text |
Enter the diagnosis pointer(s) that link this service line to the diagnosis code(s) listed in the diagnosis section.
|
| Service Line 4 Charges | Number |
Enter the total charge amount being billed for this service line.
|
| Service Line 4 Days or Units | Text |
Enter the number of days or units for the service billed on this service line.
|
| Service Line 4 EPSDT/Family Plan | Text |
Enter the EPSDT or family planning indicator for this service line, if applicable.
|
| Service Line 4 Provider ID Qualifier | Text |
Enter the qualifier that identifies the type of provider ID reported for this service line, if applicable.
|
| Service Line 4 Rendering Provider ID (Non-NPI) | Text |
Enter the rendering provider's non-NPI identifier for this service line, if required by the payer.
|
| Service Line 4 Rendering Provider NPI | Text |
Enter the rendering provider's National Provider Identifier (NPI) for this service line.
|
| Service Line 4 Rendering Provider NPI (Alternate Box) | Text |
Enter the rendering provider's National Provider Identifier (NPI) for this service line if the form uses this second identifier box.
|
| 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 | |
| Hospitalization Dates (Item 18) | ||
| Hospitalization From - Month | Text |
Enter the month the hospitalization began (FROM date).
|
| Hospitalization From - Day | Text |
Enter the day of the month the hospitalization began (FROM date).
|
| Hospitalization From - Year | Text |
Enter the year the hospitalization began (FROM date).
|
| Hospitalization To - Month | Text |
Enter the month the hospitalization ended (TO date). Fill only if 'Hospitalization From - Day' is 'Yes'.
Depends on:
Hospitalization From - Day
|
| Hospitalization To - Day | Text |
Enter the day of the month the hospitalization ended (TO date).
|
| Hospitalization To - Year | Text |
Enter the year the hospitalization ended (TO date).
|
| Illness/Injury/Other Dates (Items 14-15) | ||
| Current Illness/Injury Date - Month | Date |
Enter the month of the date of current illness, injury, or pregnancy (LMP).
|
| Current Illness/Injury Date - Day | Date |
Enter the day of the date of current illness, injury, or pregnancy (LMP).
|
| Current Illness/Injury Date - Year | Date |
Enter the year of the date of current illness, injury, or pregnancy (LMP).
|
| Current Illness/Injury Date Qualifier | Text |
Enter the qualifier code that indicates what the date of current illness, injury, or pregnancy represents.
|
| Other Date Qualifier | Date |
Enter the qualifier code that indicates what the other date represents.
|
| Other Date - Month | Date |
Enter the month for the other date indicated by the qualifier.
|
| Other Date - Day | Date |
Enter the day for the other date indicated by the qualifier.
|
| Other Date - Year | Date |
Enter the year for the other date indicated by the qualifier.
|
| Insurance Program Selection | ||
| Medicare | Checkbox |
Check this box if the patient’s coverage for this claim is through Medicare.
|
| Medicaid | Checkbox |
Check this box if the patient’s coverage for this claim is through Medicaid.
|
| TRICARE | Checkbox |
Check this box if the patient’s coverage for this claim is through TRICARE.
|
| CHAMPVA | Checkbox |
Check this box if the patient’s coverage for this claim is through CHAMPVA.
|
| Group Health Plan | Checkbox |
Check this box if the patient’s coverage for this claim is through a Group Health Plan.
|
| FECA / Black Lung | Checkbox |
Check this box if the claim is covered under FECA or the Black Lung program.
|
| Other | Checkbox |
Check this box if the patient’s coverage for this claim is through another program not listed and enter the program ID number.
|
| Insured Address & Phone | ||
| Insured Street Address | Text |
Enter the insured’s street address (number and street name).
|
| Insured City | Text |
Enter the city for the insured’s mailing address.
|
| Insured State | Text |
Enter the state for the insured’s mailing address.
|
| Insured ZIP Code | Number |
Enter the ZIP code for the insured’s mailing address.
|
| Insured Phone Area Code | Text |
Enter the area code for the insured’s telephone number.
|
| Insured Phone Number | Text |
Enter the insured's telephone number excluding the area code, as plain text in the format NNN-NNNN (e.g., 555-0192). Do not format as a number.
Example: 555-0192
|
| Insured Policy & Demographics | ||
| Insured Policy Group or FECA Number | Text |
Enter the insured person’s policy group number or FECA number as shown on the insurance information.
|
| Insured Date of Birth (Month) | Date |
Enter the month of the insured person’s date of birth.
|
| Insured Date of Birth (Day) | Date |
Enter the day of the month of the insured person’s date of birth.
|
| Insured Date of Birth (Year) | Date |
Enter the year of the insured person’s date of birth.
|
| Sex - Male (M) | Checkbox |
Check this box if the insured person is male.
|
| Sex - Female (F) | Checkbox |
Check this box if the insured person is female.
|
| Other Claim ID & Plan Name | ||
| Other Claim ID Qualifier | Text |
Enter the qualifier code that identifies the type/source of the other claim ID.
|
| Other Claim ID | Text |
Enter the other claim identification number associated with the patient’s coverage.
|
| Other Insurance Plan Name | Text |
Enter the name of the other insurance plan or program related to the other claim.
|
| Other Insured Information | ||
| Other Insured Name | Text |
Enter the other insured person’s full name (last name, first name, middle initial) as it appears on their insurance card. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Insured Policy/Group Number | Text |
Enter the policy number or group number for the other insured person’s health plan. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Reserved for NUCC Use (9b) | Text |
Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Reserved for NUCC Use (9c) | Text |
Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Insurance Plan/Program Name | Text |
Enter the name of the other insured person’s insurance plan or program. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Patient & Insured Basic Info | ||
| Insured ID Number | Text |
Enter the insured person’s identification number exactly as shown on the insurance card. Fill only if 'Medicare', 'Medicaid', 'TRICARE', 'CHAMPVA', 'Group Health Plan', 'FECA / Black Lung', 'Other' is 'Yes' (any).
Depends on:
Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA / Black Lung, Other
|
| Patient Name | Text |
Enter the patient’s full name (last name, first name, and middle initial).
|
| Patient Birth Month | Date |
Enter the month of the patient’s date of birth.
|
| Patient Birth Day | Date |
Enter the day of the month of the patient’s date of birth.
|
| Patient Birth Year | Date |
Enter the year of the patient’s date of birth.
|
| Sex: Male | Checkbox |
Check this box if the patient is male.
|
| Sex: Female | Checkbox |
Check this box if the patient is female.
|
| Insured Name | Text |
Enter the insured person’s full name (last name, first name, and middle initial).
|
| Patient Address & Phone | ||
| Patient Street Address | Text |
Enter the patient's street address (house/building number and street name).
|
| Patient City | Text |
Enter the city where the patient lives.
|
| Patient State | Text |
Enter the state where the patient lives.
|
| Patient ZIP Code | Text |
Enter the patient's ZIP or postal code.
|
| Patient Telephone (Area Code) | Text |
Enter the area code for the patient's telephone number.
|
| Patient Telephone Number | Text |
Enter the patient's telephone number.
|
| Patient Condition Related To (Employment/Accidents) | ||
| Employment? (Current or Previous) — Yes | Checkbox |
Check this box if the patient’s condition is related to current or previous employment.
|
| Employment? (Current or Previous) — No | Checkbox |
Check this box if the patient’s condition is not related to current or previous employment.
|
| Auto Accident? — Yes | Checkbox |
Check this box if the patient’s condition is related to an automobile accident.
|
| Auto Accident? — No | Checkbox |
Check this box if the patient’s condition is not related to an automobile accident.
|
| Auto Accident Location (State) | Text |
Enter the U.S. state where the auto accident occurred, if the patient’s condition is related to an auto accident. Fill only if 'Auto Accident? — Yes' is 'Yes'.
Depends on:
Auto Accident? — Yes
|
| Other Accident? — Yes | Checkbox |
Check this box if the patient’s condition is related to an accident other than an auto accident.
|
| Other Accident? — No | Checkbox |
Check this box if the patient’s condition is not related to any accident other than an auto accident.
|
| Patient Relationship to Insured | ||
| Self | Checkbox |
Check this box if the patient is the insured person (the policyholder).
|
| 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 (dependent).
|
| Other | Checkbox |
Check this box if the patient’s relationship to the insured is not self, spouse, or child.
|
| Patient/Insured Signatures & Dates | ||
| Patient/Authorized Person Signature | Text |
Enter the signature of the patient or the authorized person who is signing to authorize release of information and payment of benefits.
|
| Signature Date (Patient/Authorized Person) | Date |
Enter the date the patient or authorized person signed the form.
|
| Insured/Authorized Person Signature | Text |
Enter the signature of the insured or authorized person authorizing payment of medical benefits to the provider or supplier.
|
| Payer/Carrier Codes (PICA) | ||
| PICA Code (Left) | Text |
Enter the Payer/Carrier Code (PICA) shown on your insurance card or provided by your plan for this claim.
|
| PICA Code (Right) | Text |
Enter the Payer/Carrier Code (PICA) for the carrier receiving this claim, if a separate PICA code is required.
|
| Physician/Supplier Signature (Item 31) | ||
| Physician/Supplier Signature | Text |
Enter the signature of the physician or supplier (including degrees or credentials) certifying the claim.
|
| Signature Date | Date |
Enter the date the physician or supplier signed the claim.
|
| Prior Authorization Number (Item 23) | ||
| Prior Authorization Number | Text |
Enter the prior authorization number issued for the services being claimed (Item 23).
|
| Referring Provider Information (Item 17) | ||
| Referring provider last name | Text |
Enter the referring provider’s last name.
|
| Referring provider first name | Text |
Enter the referring provider’s first name (and middle initial if applicable).
|
| Referring provider ID qualifier (17a) | Text |
Enter the qualifier that identifies the type of non-NPI referring provider ID reported in Item 17a.
|
| Referring provider ID number (17a) | Text |
Enter the referring provider’s non-NPI identification number corresponding to the qualifier in Item 17a.
|
| Referring provider NPI (17b) | Number |
Enter the referring provider’s National Provider Identifier (NPI).
|
| Reserved for NUCC Use (Item 8) | ||
| NUCC Use (Item 8) | Text |
Enter any code or information provided by NUCC for Item 8, if applicable; otherwise leave blank.
|
| Resubmission & Original Reference (Item 22) | ||
| Resubmission Code | Text |
Enter the code that indicates this claim is a resubmission or corrected/replacement claim, if applicable.
|
| Original Reference Number | Text |
Enter the reference number or identifier for the original claim being resubmitted or corrected.
|
| Second Service Line (Item 24 - Row 2) | ||
| Service Date From (Month) | Date |
Enter the month portion of the beginning date of service for the second service line.
|
| Service Date From (Day) | Date |
Enter the day portion of the beginning date of service for the second service line.
|
| Service Date From (Year) | Date |
Enter the year portion of the beginning date of service for the second service line.
|
| Service Date To (Month) | Date |
Enter the month portion of the ending date of service for the second service line.
|
| Service Date To (Day) | Date |
Enter the day portion of the ending date of service for the second service line.
|
| Service Date To (Year) | Date |
Enter the year portion of the ending date of service for the second service line.
|
| Place of Service Code | Text |
Enter the place of service code that identifies where the services were provided for the second service line.
|
| Emergency Indicator (EMG) | Text |
Enter the emergency indicator value for the second service line, if applicable.
|
| Procedure Code (CPT/HCPCS) | Text |
Enter the CPT or HCPCS procedure/service code for the second service line.
|
| Procedure Modifier 1 | Text |
Enter the first procedure modifier associated with the procedure code for the second service line, if any.
|
| Procedure Modifier 2 | Text |
Enter the second procedure modifier associated with the procedure code for the second service line, if any.
|
| Procedure Modifier 3 | Text |
Enter the third procedure modifier associated with the procedure code for the second service line, if any.
|
| Procedure Modifier 4 | Text |
Enter the fourth procedure modifier associated with the procedure code for the second service line, if any.
|
| Diagnosis Pointer | Text |
Enter the diagnosis pointer(s) that link this service to the relevant diagnosis code(s) for the second service line.
|
| Line Item Charge Amount | Number |
Enter the total charge amount being billed for the second service line.
|
| Days or Units | Text |
Enter the number of days or units for the billed service on the second service line.
|
| EPSDT Indicator | Number |
Enter the EPSDT indicator value for the second service line, if applicable.
|
| Family Planning Indicator | Text |
Enter the family planning indicator value for the second service line, if applicable.
|
| Rendering Provider ID Qualifier | Number |
Enter the qualifier that identifies the type of rendering provider identifier reported for the second service line.
|
| Rendering Provider NPI | Text |
Enter the rendering provider's NPI for the second service line.
|
| Rendering Provider Other ID | Text |
Enter the rendering provider's other identifier (non-NPI), if applicable, for the second service line.
|
| Service Facility Location (Item 32) | ||
| Service Facility Name and Address | Text |
Enter the name and full address of the facility where the services were provided (street, city, state, and ZIP code).
|
| Service Facility NPI | Text |
Enter the National Provider Identifier (NPI) for the service facility.
|
| Service Facility Other ID | Text |
Enter any additional identification number for the service facility (if applicable).
|
| Sixth Service Line (Item 24 - Row 6) | ||
| Service Line 6 From Date (Month) | Date |
Enter the month of the beginning date of service for the sixth service line.
|
| Service Line 6 From Date (Day) | Date |
Enter the day of the beginning date of service for the sixth service line.
|
| Service Line 6 From Date (Year) | Text |
Enter the year of the beginning date of service for the sixth service line.
|
| Service Line 6 To Date (Month) | Text |
Enter the month of the ending date of service for the sixth service line.
|
| Service Line 6 To Date (Day) | Text |
Enter the day of the ending date of service for the sixth service line.
|
| Service Line 6 To Date (Year) | Text |
Enter the year of the ending date of service for the sixth service line.
|
| Service Line 6 Place of Service Code | Text |
Enter the place of service code that identifies where the service was provided for the sixth service line.
|
| Service Line 6 EMG Indicator | Text |
Enter the emergency indicator value for the sixth service line, if applicable.
|
| Service Line 6 CPT/HCPCS Code | Text |
Enter the CPT or HCPCS procedure code for the service billed on the sixth service line.
|
| Service Line 6 Modifier 1 | Number |
Enter the first procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.
|
| Service Line 6 Modifier 2 | Number |
Enter the second procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.
|
| Service Line 6 Modifier 3 | Number |
Enter the third procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.
|
| Service Line 6 Modifier 4 | Number |
Enter the fourth procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.
|
| Service Line 6 Diagnosis Pointer | Number |
Enter the diagnosis reference letter(s)/number(s) that link this service to the diagnoses listed in Item 21.
|
| Service Line 6 Charge Amount | Number |
Enter the total charge amount being billed for the sixth service line.
|
| Service Line 6 Days or Units | Number |
Enter the number of days or units for the service billed on the sixth service line.
|
| Service Line 6 EPSDT Indicator | Number |
Enter the EPSDT indicator value for the sixth service line, if applicable.
|
| Service Line 6 Family Plan Indicator | Number |
Enter the family plan indicator value for the sixth service line, if applicable.
|
| Service Line 6 Rendering Provider ID Qualifier | Text |
Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for the sixth service line, if applicable.
|
| Service Line 6 Rendering Provider Other ID | Number |
Enter the rendering provider’s non-NPI identifier for the sixth service line, if applicable.
|
| Service Line 6 Rendering Provider NPI | Text |
Enter the rendering provider’s NPI for the sixth service line.
|
| Tax ID, Patient Account & Claim Totals (Items 25-30) | ||
| Federal Tax ID Number | Text |
Enter the billing provider’s Federal Tax Identification Number (TIN).
|
| Federal Tax ID Type: SSN | Checkbox |
Check this box if the Federal Tax ID number entered in Item 25 is a Social Security Number (SSN).
|
| Federal Tax ID Type: EIN | Checkbox |
Check this box if the Federal Tax ID number entered in Item 25 is an Employer Identification Number (EIN).
|
| Patient Account Number | Text |
Enter the patient’s account number used by the provider or facility to identify this claim.
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| Accept Assignment: Yes | Checkbox |
Check this box if the provider accepts assignment of benefits for this claim.
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| Accept Assignment: No | Checkbox |
Check this box if the provider does not accept assignment of benefits for this claim.
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| Total Charge | Number |
Enter the total charges for all services reported on this claim.
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| Amount Paid | Number |
Enter the amount already paid toward this claim by the patient and/or other sources.
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| Reserved for NUCC Use (Part 1) | Number |
Enter any information required by NUCC or the payer for the first reserved segment of Item 30.
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| Reserved for NUCC Use (Part 2) | Text |
Enter any information required by NUCC or the payer for the second reserved segment of Item 30.
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| Reserved for NUCC Use (Part 3) | Text |
Enter any information required by NUCC or the payer for the third reserved segment of Item 30.
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| Reserved for NUCC Use (Part 4) | Text |
Enter any information required by NUCC or the payer for the fourth reserved segment of Item 30.
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| Third Service Line (Item 24 - Row 3) | ||
| From Date of Service - Month | Date |
Enter the month of the start (FROM) date of service for this third service line.
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| From Date of Service - Day | Date |
Enter the day of the start (FROM) date of service for this third service line.
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| From Date of Service - Year | Text |
Enter the year of the start (FROM) date of service for this third service line.
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| To Date of Service - Month | Text |
Enter the month of the end (TO) date of service for this third service line, if different from the from date.
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| To Date of Service - Day | Text |
Enter the day of the end (TO) date of service for this third service line, if different from the from date.
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| To Date of Service - Year | Text |
Enter the year of the end (TO) date of service for this third service line, if different from the from date.
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| Place of Service | Text |
Enter the place of service code for where the service was performed on this third service line.
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| Emergency Indicator | Text |
Enter the emergency indicator for this third service line, if applicable.
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| Procedure/Service Code (CPT/HCPCS) | Text |
Enter the CPT/HCPCS procedure or service code billed on this third service line.
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| Modifier 1 | Text |
Enter the first procedure modifier for the CPT/HCPCS code on this third service line, if applicable.
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| Modifier 2 | Text |
Enter the second procedure modifier for the CPT/HCPCS code on this third service line, if applicable.
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| Modifier 3 | Text |
Enter the third procedure modifier for the CPT/HCPCS code on this third service line, if applicable.
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| Modifier 4 | Text |
Enter the fourth procedure modifier for the CPT/HCPCS code on this third service line, if applicable.
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| Diagnosis Pointer | Text |
Enter the diagnosis code reference letter(s) (from Item 21) that apply to this third service line.
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| Charges - Dollars | Number |
Enter the dollar amount charged for this third service line.
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| Charges - Cents | Text |
Enter the cents portion of the amount charged for this third service line.
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| Days or Units | Text |
Enter the number of days or units for the service billed on this third service line.
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| EPSDT/Family Plan | Text |
Enter the EPSDT/Family Plan indicator for this third service line, if applicable.
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| Rendering Provider ID Qualifier | Text |
Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for this third service line, if applicable.
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| Rendering Provider NPI | Text |
Enter the rendering provider's NPI for this third service line.
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| Rendering Provider Other ID | Number |
Enter the rendering provider's non-NPI identifier for this third service line, if applicable.
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| Unable to Work Dates (Item 16) | ||
| Unable to Work From (Month) | Date |
Enter the month when the patient first became unable to work in their current occupation.
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| Unable to Work From (Day) | Date |
Enter the day of the month when the patient first became unable to work in their current occupation.
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| Unable to Work From (Year) | Date |
Enter the year when the patient first became unable to work in their current occupation.
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| Unable to Work To (Month) | Date |
Enter the month when the patient returned to work (or the end month of the period they were unable to work).
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| Unable to Work To (Day) | Date |
Enter the day of the month when the patient returned to work (or the end day of the period they were unable to work).
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| Unable to Work To (Year) | Text |
Enter the year when the patient returned to work (or the end year of the period they were unable to work).
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