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Last Modified: 4/14/2022 Location: FL, PR, USVI Business: Part B

CMS-1500 (02/12) data element requirements

The National Uniform Claim Committee (NUCC) has created a presentation that reviews the changes to the revised form in detail. Click here external pdf file to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.
Click here external pdf file to view a sample of the form
Note: If submitting paper claim forms, ensure to use only original red and white forms. Black and white copies will be returned as unprocessable.
Status Key:
R = Completion of this item is required by Medicare for every claim
C = Completion of this item is conditionally required based on certain circumstances
NR = Completion of this item is not required by Medicare
Claims missing, or containing incomplete, or invalid information for any required or conditionally required item will be returned as unprocessable.
Note: Providers can utilize the First Coast PC-ACE software to submit claims electronically. PC-ACE software has built-in edits to avoid submitting claims without required information being included. Click here for additional information on PC-ACE.
Some item numbers contain links to First Coast provider resources, providing additional information.

Item Number
Item Description and Guidance
Requirement Status
837P Professional Version 5010/5010A1
1
Type of insurance
R
Loop ID 2000B
Segment/Data Element -- SBR09
1a
Patient’s Medicare ID
R
Loop ID 2010BA
Segment/Data Element -- NM109
2
Enter the patient’s last name, first name, and middle initial (if any), as shown on patient’s Medicare card.
R
Loop ID 2010CA or 2010BA
Segment/Data Element:
NM103
NM104
NM105
NM107
3
Enter the patient’s eight-digit birth date (MM/DD/CCYY) and sex.
R
Loop ID 2010CA or 2010BA
Segment/Data Element:
DMG02
DMG03
4
Insured’s name
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 6, 7, and 11a-c are completed.)
C
Loop ID 2010BA
Segment/Data Element:
NM103
NM104
NM105
NM107
5
Patient’s mailing address, city, state, and phone number
R
Loop ID 2010CA
Segment/Data Element:
N302
N401
N402
N403
6
Check appropriate box for patient’s relationship to insured.
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 7, and 11a-c are completed.)
C
Loop ID 2000B
Segment/Data Element:
SBR02
Loop ID 2000C
Segment/Data Element:
PAT01
7
Insured’s address and telephone number.
Note
: When address is the same as patient’s, enter the word SAME.
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 6, and 11a-c are completed.)
C
Loop ID 2010BA
Segment/Data Element:
N301
N302
N401
N402
N403
8
Leave blank -- Medicare Part B Providers are not required to complete.
NR
Loop ID N/A
Segment/Data Element:
N/A
9
Other Insured’s Name
C
Loop ID 2330A
Segment/Data Element:
NM103
NM104
NM105
NM107
9a
Other Insured’s Policy or Group Number
C
Loop ID 2320
Segment/Data Element:
SBR03
9b
Leave blank -- Reserved for NUCC Use (previously Other Insured’s Date of Birth, Sex)
NR
Loop ID N/A
Segment/Data Element:
N/A
9c
Leave blank if item 9d is completed. -- Reserved for NUCC Use (previously Employer’s Name or School Name)
NR
Loop ID N/A
Segment/Data Element:
N/A
9d
Insurance Plan Name or Program Name
C
Loop ID 2320
Segment/Data Element:
SBR04
10a-c
Employment/accident indicators
R
Loop ID 2300 (Items 10a-10c)
Segment/Data Element:
CLM11 (Items 10a-10c)
10d
C
Loop ID 2300
Segment/Data Element:
HI
Primary insurance policy number
Note
: Enter the word NONE if Medicare is primary
R
Loop ID 2000B
Segment/Data Element:
SBR03
Insured’s Date of Birth, Sex
C
Loop ID 2010BA
Segment/Data Element:
DMG02
DMG03
Other Claim ID (previously Insured’s Employer Name or School Name)
C
Loop ID 2010BA
Segment/Data Element:
REF01
REF02
Insurance Plan Name or Program Name
C
Loop ID 2000B
Segment/Data Element:
SBR04
Another health benefit plan
Leave blank -- Medicare Part B Providers are not required to complete.
NR
Loop ID 2320
Segment/Data Element:
N/A
12
Patient’s signature and date
R
Loop ID 2300
Segment/Data Element:
CLM09
13
Patient signature -- Medigap authorization
Note
: Must be completed if information contained in 9-9d.
C
Loop ID 2300
Segment/Data Element:
CLM08
14
Date of current illness, injury, or pregnancy
Note: Although space for a qualifier is included, Medicare does not use this information; do not enter a qualifier in item 14.
C
Loop ID 2300
Segment/Data Element:
DTP01
DTP03
15
Leave blank -- Medicare Part B Providers are not required to complete.
NR
Loop ID 2300
Segment/Data Element:
DTP01
DTP03
16
If patient is employed, enter dates patient will be unable to work in current occupation.
C
Loop ID 2300
Segment/Data Element:
DTP03
Enter the name and qualifier of the referring, ordering or supervising physician if the item or service was ordered, supervised or referred by a physician.
The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
DN -- referring provider
DK -- ordering provider
DQ -- supervising provider
Enter the qualifier to the left of the dotted vertical line on item 17.
Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC).
See Claim completion FAQs on the First Coast provider website for additional details for reporting referring/ordering providers.
See also the Part A and B: Provider enrollment FAQs for additional guidance.
C
Required if services are ordered, referred or supervised
Loop ID 2310A (Referring), 2310D (Supervising), 2420E (Ordering)
Segment/Data Element:
NM101
NM103
NM104
NM105
NM107
DO NOT complete
NR
Loop ID 2310A (Referring), 2310D (Supervising), 2420E (Ordering)
Segment/Data Element:
REF01
REF02
If the service is referred or ordered, enter the national provider identifier (NPI) of the referring/ordering individual provider only.
C
Required if services are ordered, referred or supervised
Loop ID 2310A (Referring), 2310D (Supervising), 2420E (Ordering)
Segment/Data Element:
NM109
18
Hospitalization dates
C
Loop ID 2300
Segment/Data Element:
DTP03
19
Additional claim information
See CMS IOM Pub 100-04, Chapter 26, Section 10.4 external pdf file for guidance on completion of Item 19
C
Loop ID 2300
Segment/Data Element:
NTE
PWK
Loop ID 2310A (Referring), 2310B (Rendering), 2310C (Service Facility), 2310D, (Supervising)
Segment/Data Element:
REF01
REF02
20
Outside lab
See Claim completion FAQs on the First Coast provider website for additional details for reporting purchased services.
C
Loop ID 2400
Segment/Data Element:
PS102
Report up to twelve primary diagnosis codes
For dates of service prior to October 1, 2015 -- report ICD-9-CM codes. Enter the ICD indicator 9 as a single digit between the vertical, dotted lines.
For dates of service on and after October 1, 2015 -- report ICD-10-CM codes. Enter the ICD indicator 0 as a single digit between the vertical, dotted lines.
If submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.
R
Loop ID 2300
Segment/Data Element:
HI01-2, HI02-2
HI03-2, HI04-2
HI05-2, HI06-2
HI07-2, HI08-2
HI09-2, HI10-2
HI11-2, HI12-2
22
Leave blank -- Medicare Part B Providers are not required to complete.
NR
Loop ID 2300
Segment/Data Element:
CLM05-3
REF02
23
Prior authorization number
See CMS IOM Pub 100-04, Chapter 26, Section 10.4 external pdf file for guidance.
C
Loop ID 2300
Segment/Data Element:
REF02
24A
Date(s) of service (DOS)
R
Loop ID 2400B
Segment/Data Element:
DTP03
R
Loop ID 2300
Segment/Data Element:
CLM05-1
Loop ID 2400
Segment/Data Element:
SV105
24C
Leave blank -- Medicare Part B Providers are not required to complete.
NR
Loop ID 2400
Segment/Data Element:
SV109
24D
R
Loop ID 2400
Segment/Data Element:
SV101 (2-6)
Diagnosis pointer
Note: the reference will be a letter from A-L. This information appears opposite the diagnosis codes in Item 21. Relate lines A- L to lines of service in 24E by the letter of the line.
R
Loop ID 2400
Segment/Data Element:
SV107 (1-4)
24F
Charge (in dollars) for service
R
Loop ID 2400
Segment/Data Element:
SV102
24G
Days/Units
R
Loop ID 2400
Segment/Data Element:
SV104
24H
Leave blank -- Medicare Part B Providers are not required to complete.
NR
Loop ID 2400
Segment/Data Element:
SV111
SV112
24I
Leave blank -- Medicare Part B Providers are not required to complete.
NR
Loop ID 2310B
Segment/Data Element:
PRV02
REF01
Loop ID 2420
Segment/Data Element:
PRV02
REF01
Enter the NPI of the rendering provider in the lower non-shaded portion.
Do not report anything in the upper shaded portion of item 24J.
C
Loop ID 2310B
Segment/Data Element:
NM109
Loop ID 2420A
Segment/Data Element:
NM109
25
Federal tax identification number (TIN)
C
Loop ID 2010AA
Segment/Data Element:
REF01
REF02
26
Patient’s account number
C
Loop ID 2300
Segment/Data Element:
CLM01
27
Assignment
See CMS IOM Pub 100-04, Chapter 1, Section 30.3.1 external pdf file for list of provider and claim types for which assignment must always be accepted.
R
Loop ID 2300
Segment/Data Element:
CLM07
28
Total Charges
R
Loop ID 2300
Segment/Data Element:
CLM02
29
Enter amount collected from patient, if any.
Note
: Please review When not to show patient paid amounts on claims article before collecting payments from patients.
C
Loop ID 2300
Segment/Data Element:
AMT02
Loop ID 2320
Segment/Data Element:
AMT02
30
Leave blank -- Medicare Part B Providers are not required to complete.
NR
Loop ID N/A
Segment/Data Element:
N/A
31
Provider signature and date
Note:
"Signature on File" and/or a computer-generated signature are acceptable. See CMS IOM Pub. 100-04, chapter 26, section 10.4 Item 32 external pdf file for details
R
Loop ID 2300
Segment/Data Element:
CLM06
For services payable under the Medicare Physician Fee Schedule (MPFS) and anesthesia services:
Name, address and ZIP of location where services were rendered for all locations.
Note:
As of January 1, 2011, all locations (including patient's home) must be reported.
R
Loop ID 2310C
Segment/Data Element:
NM103
N301
N401
N402
N403
If reporting anti-markup services (formerly purchased diagnostic services), enter the NPI of the provider who performed the service.
Note: Effective on or after April 1, 2015, for reference laboratory and anti-markup claims, billing physicians and suppliers are required to report the name, address, ZIP code, and NPI of the performing physician or supplier when the performing physician or supplier is enrolled in a different contractor’s jurisdiction. Physicians and other suppliers will no longer be permitted to submit their own NPI in Item 32a (or its electronic equivalent) when the performing physician or supplier is in another jurisdiction.
Example 1 (Puerto Rico): If a San Juan provider purchases a service performed by a provider in San Sebastian, the San Sebastian provider's address and NPI should be reported.
Example 2 (Florida): If a Jacksonville, Florida provider purchases a diagnostic service from a mobile provider located in Kingsland, Georgia, they would report the physical location and NPI of the provider where services were performed (Kingsland, GA).
C
Loop ID 2310C
Segment/Data Element:
NM109
32b
DO NOT complete
NR
Loop ID 2310C
Segment/Data Element:
REF01
REF02
Billing provider’s name, address, ZIP and telephone number
R
Loop ID 2010AA
Segment/Data Element:
NM103
NM104
NM105
NM107
N301
N401
N402
N403
PER04
Enter the NPI of the billing provider or group.
R
Loop ID 2010AA
Segment/Data Element:
NM109
DO NOT complete
NR
Loop ID 2000A
Segment/Data Element
PRV03
Loop ID 2010AA
Segment/Data Element:
REF01
REF02
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.