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Last Modified: 2/11/2025 Location: FL, PR, USVI Business: Part A

EDI: CMS-1450 paper claim to electronic claim crosswalk (5010)

The following chart provides a crosswalk for several blocks on the 1450 (UB-04) paper claim form and the equivalent electronic data in the ANSI ASC X12N format, version 5010. The form locators (FL) listed are the required for electronic claims. Any FL not listed are not needed on the electronic claim.
For additional information regarding loops and segments, please access the 5010 Companion Guides.

FL
Field description
Loops
Segments
Qualifiers
Electronic description
01
Provider name
2010AA
NM1
85
Billing provider name
01
Provider address
2010AA
N3, N4
N/A
Billing provider address
02
Pay-to name
2010AB
NM1
87
Pay-to name
02
Pay-to address
2010AB
N3, N4
N/A
Pay-to address
03a
Patient’s control number
2300
CLM
N/A
Patient’s control number
03c
Medical record number
2300
REF
EA
Medical Reference number
04
Type of bill
2300
CLM5-1, CLM05-3
N/A
Type of Bill
05
Fed. Tax No.
2010AA
REF
EI
Billing provider tax ID
06
Statement covers period (from; through)
2300
DTP
434
Statement dates
08a
Patient’s name
2010BA
NM1
IL
Subscriber name
09a-09e
Patient’s address
2010BA
N3, N4
N/A
Subscriber address
10
Birth date
2010BA
DMG
D8
Subscriber demographic info
11
Sex
2010BA
DMG
N/A
Subscriber demographic info
12
Admission date
2300
DTP
435
Admission date/HR
13
Admission hour
2300
DTP
DT
Admission date/HR
14
Admission type
2300
CL1
N/A
Institutional claim code
15
Admission source
2300
CL1
N/A
Institutional claim code
17
STAT
2300
CL1
N/A
Institutional claim code
18-28
Condition codes
2300
HI
BG
Condition info
31-36
Occurrence code/Date
2300
HI
BH
Occurrence info
39-41
Value code code/Amount
2300
HI
BE
Value info
A value code of one of the following values must be reported if 2000B SBR01="S"
12, 13, 14, 15, 16, 41, 42, 43, or 47
42
Revenue Code
2400
SV2
N/A
Revenue code
44
HCPCS/RATE/HIPPS CODE
2400
SV2
HC
HCPCS/Rate/HIPPS code
45
Service date
2400
DTP
472
Date of service
46
Service units
2400
SV2
UN -UNITS
DA - DAYS
Service units
47
Total charges
2400
SV2
N/A
Total charges
48
Non-covered charges
2400
SV2
N/A
Non-covered charges
50
Payer name
2000B
SBR
N/A
Payer name
51
Health plan ID
2000B
SBR
N/A
Health plan ID
52
Release of info
2300
CLM
N/A
Release of info
53
Assignment of benefits
2300
CLM
N/A
Assignment of benefits
55
Estimated amount due
2300
AMT
F3
Patient estimated amount due
56
National Provider Identifier (NPI)
2010AA
NM1
XX
NPI
57
Other Prv. ID
2310C
NM1
73
N/A
58
Insured’s name
2010BA
NM1
IL
Insured’s name
59
Patient relationship
2000B
SBR
18
N/A
60
Insured’s unique ID
2010BA
REF
N/A
Insured’s unique ID
63
Treatment authorization codes
2300
REF
G1
Treatment authorization codes
64
Document control number
2300
REF
F8
Document control number
65
Employer name
2320
SBR
N/A
N/A
67
Dx.
2300
HI
ABK
Principal diagnosis code
67a-q
Other dx
2300
HI
ABF
Other diagnosis code
69
Admit dx.
2300
HI
ABJ
Admitting diagnosis code
70
Patient reason dx
2300
HI
ZZ
Patient reason for visit
71
Prospective payment system (PPS) code
2400
SV2
N/A
PPS code
74
Principle procedure code
2300
HI
BBR
Principle procedure code
74
Principle procedure date
2300
HI
D8
Principle procedure date
74b
Other procedure code
2300
HI
BBQ
Other procedure code
74b
Other procedure date
2300
HI
D8
Other procedure date
74d
Other procedure code
2300
HI
BBQ
Other procedure code
74d
Other procedure date
2300
HI
D8
Other procedure date
76
Attending (NPI, qualifier, last name, first name)
2310A
NM1
71
Attending name/NPI
77
Operating (NPI, qualifier, last name, first name)
2420A
NM1
72
Operating name/NPI
78
Other (NPI, qualifier, last name, first name)
2420B
NM1
ZZ
Other provider name/NPI
79
Other (NPI, qualifier, last name, First name)
2420B
NM1
ZZ
Other Provider Name/NPI
80
Remarks
2300
NTE
N/A
Remarks
81
Health care taxonomy code
2000A
PRV
PXC
Taxonomy code
81a
Condition code
2300
HI
BG
Condition code
81b-c
Occurrence code
2300
HI
BH/BI
Occurrence code
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.