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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