NUCC 1500 Claim Form (HCFA) Crosswalk to 837

This help article explains what on the 1500 Claim Form (HCFA) corresponds to the 837 EDI file. This document* is intended to be used in conjunction with the NUCC Data Set. Please refer to the NUCC’s 1500 Reference Instruction Manual for more specific information on the 1500 Claim Form and Item Numbers. Please refer to the X12 Health Care Claim: Professional (837) Technical Report Type 3 for more specific details on the transaction and data elements.

*Note: The source of this help article is National Uniform Claim Committee's 1500 Claim Form Map to the X12 Health Care Claim: Professional (837).

1500 Form Locator		837P		Notes
Item Number	Title	Loop ID	Segment/Data Element	Notes
N/A	Carrier Block	2010BB	NM103 N301 N302 N401 N402 N403
1	Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other	2000B	SBR09	Titled Claim Filing Indicator Code in the 837P.
1a	Insured's ID Number	2010BA	NM109	Titled Subscriber Primary Identifier in the 837P.
2	Patient's Name	2010CA or 2010BA	NM103 NM104 NM105 NM107
3	Patient's Birth Date, Sex	2010CA or 2010BA	DMG02 DMG03	Titled Gender in the 837P.
4	Insured's Name	2010BA	NM103 NM104 NM105 NM107	Titled Subscriber in the 837P.
5	Patient's Address	2010CA	N302 N401 N402 N403
6	Patient Relationship to Insured	2000B	SBR02	Titled Individual Relationship Code in the 837P.
6	Patient Relationship to Insured	2000C	PAT01	Titled Individual Relationship Code in the 837P.

7	Insured's Address	2010BA	N301 N302 N401 N402 N403	Titled Subscriber Address in the 837P.
8	Reserved for NUCC Use (previously Patient Status)	N/A	N/A	Patient Status was removed. Patient Status does not exist in the 837P.
9	Other Insured's Name	2330A	NM103 NM104 NM105 NM107	Titled Other Subscriber Name in the 837P.
9a	Other Insured’s Policy or Group Number	2320	SBR03	Titled Insured Group or Policy Number in the 837P.
9b	Reserved for NUCC Use (previously Other Insured’s Date of Birth, Sex)	N/A	N/A	Other Insured’s Date of Birth, Sex was removed. Other Insured’s Date of Birth and Sex do not exist in the 837P.
9c	Reserved for NUCC Use (previously Employer's Name or School Name)	N/A	N/A	Employer's Name or School Name was removed. Employer’s Name and School Name do not exist in the 837P.
9d	Insurance Plan Name or Program Name	2320	SBR04	Titled Other Insured Group Name in the 837P.
10a	Is Patient's Condition Related to: Employment	2300	CLM11	Titled Related Causes Code in the 837P.
10b	Is Patient's Condition Related to: Auto Accident	2300	CLM11	Titled Related Causes Code in the 837P.
10c	Is Patient's Condition Related to: Other Accident	2300	CLM11	Titled Related Causes Code in the 837P.

10d	Claim Codes (previously Reserved for Local Use)	2300	HI	HI is for reporting other Condition Codes.
11	Insured's Policy, Group, or FECA Number	2000B	SBR03	Titled Subscriber Group or Policy Number in the 837P.
11a	Insured's Date of Birth, Sex	2010BA	DMG02 DMG03	Titled Subscriber Birth Date and Subscriber Gender Code in the 837P.
11b	Other Claim ID (previously Insured's Employer Name or School Name)	2010BA	REF01 REF02	Changed to Other Claim ID. Insured's Employer Name or School Name does not exist in 837P.
11c	Insurance Plan Name or Program Name	2000B	SBR04	Titled Subscriber Group Name in the 837P.
11d	Is there another Health Benefit Plan?	2320		Presence of Loop 2320 indicates Y (yes) to the question.
12	Patient's or Authorized Person's Signature	2300	CLM09	Titled Release of Information Code in the 837P.
13	Insured's or Authorized Persons Signature	2300	CLM08	Titled Benefits Assignment Certification Indicator in the 837P.
14	Date of Current Illness, Injury, Pregnancy (LMP)	2300	DTP01 DTP03	Titled in the 837P: Date – Onset of Current Illness or Symptom Date – Last Menstrual Period

15	Other Date (previously If Patient Has Had Same or Similar Illness)	2300	DTP01 DTP03	Titled in the 837P: Date – Initial Treatment Date Date – Last Seen Date Date – Acute Manifestation Date – Accident Date – Last X-ray Date Date – Hearing and Vision Prescription Date Date – Assumed and Relinquished Care Dates Date – Property and Casualty Date of First Contact If Patient Has Had Same or Similar Illness does not exist in 837P.
16	Dates Patient Unable to Work in Current Occupation	2300	DTP03	Titled Disability From Date and Work Return Date in the 837P.
17	Name of Referring Provider or Other Source	2310A (Referring) 2310D (Supervising) 2420E (Ordering)	NM101 NM103 NM104 NM105 NM107
17a	Other ID#	2310A (Referring) 2310D (Supervising) 2420E (Ordering)	REF01 REF02	Titled Referring Provider Secondary Identifier, Supervising Provider Secondary Identifier, and Ordering Provider Secondary Identifier in the 837P.
17b	NPI #	2310A (Referring) 2310D (Supervising) 2420E (Ordering)	NM109	Titled Referring Provider Identifier, Supervising Provider Identifier, and Ordering Provider Identifier in the 837P.
18	Hospitalization Dates Related to Current Services	2300	DTP03	Titled Related Hospitalization Admission Date and Related Hospitalization Discharge Date in the 837P.

19	Additional Claim Information (previously Reserved for Local Use)	2300	NTE
		2300	PWK
		2310A (Referring) 2310B (Rendering) 2310C (Service Facility) 2310D (Supervising)	REF01 REF02
20	Outside Lab Charges	2400	PS102	Titled Purchased Service Charge Amount in the 837P.
21	Diagnosis or Nature of Illness or Injury	2300	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	Resubmission and/or Original Reference Number	2300	CLM05-3	Titled Claim Frequency Code in the 837P.
22	Resubmission and/or Original Reference Number	2300	REF02	Titled Payer Claim Control Number in the 837P.
23	Prior Authorization Number	2300	REF02	Titled Prior Authorization Number in the 837P.
		2300	REF02	Titled Referral Number in the 837P.
		2300	REF02	Titled Clinical Laboratory Improvement Amendment Number in the 837P.
		2300	REF02	Titled Mammography Certification Number in the 837P.
24A	Date(s) of Service	2400	DTP03	Titled Service Date in the 837P.
24B	Place of Service	2300	CLM05-1	Titled Facility Code Value in the 837P.
24B	Place of Service	2400	SV105	Titled Place of Service Code in the 837P.

24C	EMG	2400	SV109	Titled Emergency Indicator in the 837P.
24D	Procedures, Services, or Supplies	2400 2400	SV101 (2-6)	Titled Product/Service ID and Procedure Modifier in the 837P.
24E	Diagnosis Pointer	2400	SV107 (1-4)	Titled Diagnosis Code Pointer in the 837P. Alpha pointers on the 1500 claim form MUST be converted to numeric pointers in the 837P.
24F	$ Charges	2400	SV102	Titled Line Item Charge Amount in the 837P.
24G	Days or Units	2400	SV104	Titled Service Unit Count in the 837P.
24H	EPSDT/Family Plan	2400	SV111 SV112	Titled EPSDT Indicator and Family Planning Indicator in the 837P.
24I Shaded Line	ID Qualifier	2310B	PRV02 REF01	Titled Reference Identification Qualifier in the 837P.
24I Shaded Line	ID Qualifier	2420A	PRV02 REF01	Titled Reference Identification Qualifier in the 837P.
24J Shaded Line	Rendering Provider ID #	2310B	PRV03 REF02	Titled Provider Taxonomy Code and Rendering Provider Secondary Identifier in the 837P.
24J Shaded Line	Rendering Provider ID #	2420A	PRV03 REF02	Titled Provider Taxonomy Code and Rendering Provider Secondary Identifier in the 837P.
24J	Rendering Provider ID #	2310B	NM109
24J	Rendering Provider ID #	2420A	NM109	Titled Rendering Provider Identifier in the 837P.
25	Federal Tax ID Number	2010AA	REF01 REF02	Titled Reference Identification Qualifier and Billing Provider Tax Identification Number in the 837P.
26	Patient's Account No.	2300	CLM01	Titled Patient Control Number in the 837P.

27	Accept Assignment?	2300	CLM07	Titled Assignment or Plan Participation Code in the 837P.
28	Total Charge	2300	CLM02	Titled Total Claim Charge Amount in the 837P.
29	Amount Paid	2300	AMT02	Titled Patient Amount Paid in the 837P.
29	Amount Paid	2320	AMT02	Titled Payer Paid Amount in the 837P.
30	Rsvd for NUCC Use (previously Balance Due)	N/A	N/A	Balance Due was removed. Balance Due does not exist in the 837P.
31	Signature of Physician or Supplier Including Degrees or Credentials	2300	CLM06	Titled Provider or Supplier Signature Indicator in the 837P.
32	Service Facility Location Information	2310C	NM103 N301 N401 N402 N403
32a	NPI #	2310C	NM109	Titled Laboratory or Facility Primary Identifier in the 837P.
32b	Other ID #	2310C	REF01 REF02	Titled Reference Identification Qualifier and Laboratory or Facility Secondary Identifier in the 837P.
33	Billing Provider Info & Ph #	2010AA	NM103 NM104 NM105 NM107 N301 N401 N402 N403 PER04
33a	NPI #	2010AA	NM109	Titled Billing Provider Identifier in the 837P.

33b	Other ID #	2000A	PRV03	Titled Provider Taxonomy Code in the 837P.
33b	Other ID #	2010AA	REF01 REF02	Titled Reference Identification Qualifier and Billing Provider Additional Identifier in the 837P.

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NUCC 1500 Claim Form (HCFA) Crosswalk to 837

NUCC 1500 Claim Form (HCFA) Crosswalk to 837

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