NUCC 1500 Claim Form (HCFA) Crosswalk to 837

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

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.

2000C

PAT01

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.

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.

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.

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.

2420A

PRV03
REF02

Titled Provider Taxonomy Code and Rendering Provider Secondary Identifier in the 837P.

24J

Rendering Provider ID #

2310B

NM109


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.

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.

2010AA

REF01
REF02

Titled Reference Identification Qualifier and Billing Provider Additional Identifier in the 837P.



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