| Box# | Contents Name | EDI Looping/Segment | CT Process (from where/which screen values are pulled |
| 1 | Health Plan | Payer Set up Insurance Type Drop Down List | Screen: Practice Management- Payer Set up ; Field: Insurance Type |
| 1a | Insured’s ID Number | Loop 2010BA, NM1/IL, 09 | Screen: Patient Payer Information; Field: Insurance ID |
| 2 | Patient’s Name | Loop 2010BA, NM1/IL, 03 and 04 | Screen: Patient General Information; Field: First Name, Last Name |
| 3 | Birth Date and Gender | 2010BA, DMG, 02; 2010, DMG, 03 | Screen: Patient General Information; Field: Date of Birth, Gender |
| 4 | Insured’s Name | 2330, NM1/IL, 03 AND 04 | Screen: Patient General Information (if same as patient) IF NOT same as patient, THEN Screen: Payer Information, Insured Information; Field: First Name, Last Name |
| 5 | Patient Address | 2010BA, N3, 01; 2010BA, N4, 01 (City); 2010BA, N4, 02 (State); 2010BA, N4, 03 (Zip) | Screen: Patient General Information; Field: Address, City, State, Zip Code |
| 6 | Patient’s Relationship to Insured | 2000B, SBR, 02 | Screen: Payer Information, Insured Information; Field: Relation; Fixed Value IF Self; IF NOT SELF: select the Patient’s relation to the policy holder (child, spouse, other) |
| 7 | Insured’s Name and Address (city, state, zip, phone number) | Patient General Fields 2a-d | ONLY used if Insurance Policy Holder is different than Patient; Screen: Payer Information, Insured Information; Fields: First Name, Last Name, DOB, Gender, Address, City, State, Zip, Phone No. |
| 8 | Reserved for NUCC use | NA | Not Used |
| 9 | Other Insured Name | 2330A, NM1/IL, 03, 04, and 05 | *Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the name (last name, first name, middle initial) of the person who is insured under the other payer. Screen: Patient Payer; Field: Last Name, First Name |
| 9a | Other Insured Policy | 2330A, NM1/IL, 09 | Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the other insured’s policy or group number or the insured’s identification number. Screen: Patient Payer; Field: Insurance ID |
| 9b | Reserved for NUCC use | NA | Not Used |
| 9c | Reserved for NUCC use | 2330B, NM1/PR, 03 | Not Used |
| 9d | Insurance Plan Name or Program Name | 2330B, NM1/PR, 09 | Required if Field 11d is marked “yes” or if there is other insurance involved with the reimbursement of this claim. Enter the other insured’s insurance company or program name. Screen: Payer; Field: Payer ID (secondary or tertiary) |
| 10 | Is Patient’s Condition Related to: | 2300, CLM, 11 | Place an “X” in the box indicating whether or not the condition for which the member is being treated is related to current or previous employment, an automobile accident or any other accident. Enter an “X” in either the YES or NO box for each question. Screen: SOAP; Field: Accident Reason |
| 10a | Employment | 2300, CLM, 11 | Screen: SOAP; Field: Accident Reason |
| 10b | Auto Accident | 2300, CLM, 11 | NOTE: The state postal code must be shown if “yes” is marked in 10b for “auto accident.” Any item marked yes indicates there may be other applicable insurance coverage that would be primary such as automobile liability insurance. Primary insurance information must then be shown in item 11. Screen: SOAP; Field: Accident Reason |
| 10c | Other Accident | 2300, CLM, 11 | Screen: SOAP; Field: Accident Reason |
| 10d | Claim Codes | 2300, CLM, 11 | Screen: SOAP; Field: Accident Reason |
| 11 | Insured’s Policy Group Number | There is no direct match for Blocks 11-11D of the CMS-1500 form to the ANSI 837 v5010 format. | Enter the Insured’s policy or group number as it appears on the insured’s health care identification card. Screen: Patient Payer Information; Field: Group Number |
| 11a | Insured’s DOB / Gender | There is no direct match for Blocks 11-11D of the CMS-1500 form to the ANSI 837 v5010 format | Required if the member is not the insured. Enter the insured’s birth date and gender if different from box 3. Screen: Patient General Information; Field: Patient DOB and Patient Gender |
| 11b | Other Claim ID | There is no direct match for Blocks 11-11D of the CMS-1500 form to the ANSI 837 v5010 format | N/A |
| 11c | Insurance Plan Name | There is no direct match for Blocks 11-11D of the CMS-1500 form to the ANSI 837 v5010 format | Screen: Payer; Field: Payer Name |
| 11d | Is There Another Health Benefit Plan | Screen: Patient Payer; Field: X Marks yes if ‘Is Active’ is true. Payer Preference is marked as secondary or tertiary | |
| 12 | Patient Signature | 2300, CLM, 10 | Sending C fixed value ‘Signature on File’ Screen: SOAP; Field: Add Patient Signature |
| 13 | Insured’s Authorized Signature | Sending C fixed value ‘Signature on File’ Screen: SOAP; Field: Add Patient Signature | |
| 14 | Date of Current Illness, Injury | 2300, DTP/439, 03 | Screen: SOAP; Field: Date of Onset ( if payer set as ‘Include Accident Date In EDI’) DTP in EDI needs to be checked for medicare claims for date of onset to show in box 14 |
| 15 | Other Date | Screen: SOAP; Field: Click X-ray on bottom of SOAP for date you wish to display in box 15 ( if payer set as ‘include X-ray date’) | |
| 16 | Dates Patient Unable to Work In Current | N/A | N/A |
| 17 | Name of Referring Provider | 2300 or 2400, DTP/431, 03 | Screen: Practice Management; Field: Referring Providers. Must be assigned to patient and checked as ‘Main’ is true. Drop down box ‘Referring Provider’ . |
| 17a | Reserved NUCC | N/A | |
| 17b | NPI | 2420E, NM1/DK, 09 | Screen: Practice Management; Field: Referring Providers- NPI |
| 18 | Hospitalization Dates Related to Current Services | N/A | N/A |
| 19 | Additional Claim Information | N/A | Screen: Payer; Field: click ‘Include standard text’ type into additional claim info |
| 20 | Outside Lab | 2400, PS1, 02 | N/A |
| 21 | Diagnosis or Nature of Illness or Injury | 2300, HI, 01-2 | Screen: SOAP; Field: Billing Information, DX Code Type |
| 22 | Resubmission Code | N/A | N/A |
| 23 | Prior Authorization Code | 2300 or 2400, REF/X4, 02 | N/A |
| 24a | Date of Service | 2400, DTP/472, 03 | Screen: SOAP; Field: Date of Service |
| 24b | Place of Service | 2300, CLM, 05 or 2400, SV1, o5 | Standard ’11’ office |
| 24c | EMG | N/A | N/A |
| 24d | Procedures, Services, Supplies | 2400, SV1, 01-2 | Screen: Billing; Field: CPT Code |
| 24e | Diagnosis Pointer | 2400, SV1, 07-1 | Screen: Charges (Diagnosis Pointers); Field: Diagnosis codes can be selected for each CPT code |
| 24f | Charges | Pulls from Billing | Screen: Billing; Field: Total Charge |
| 24g | Days or Units | 2400, SV1, 04 (03=UN) | Screen: Billing; Field: Units |
| 24h | EPSDT Family Plan | N/A | N/A |
| 24i | ID Qualifier | N/A | N/A |
| 24j | Rendering Provider Number | N/A | Screen: Edit Profile; Field: NPI # |
| 25 | Federal Tax Id Number | 2010AA, REF, 02 (REF01=EI or SY) | Screen: Practice Management, Practice Group; Field: Tax ID |
| 26 | Patient’s Account Number | 2300, CLM, 01 | Automatically sent (Billing ID) |
| 27 | Accept Assignment | 2300, CLM, 07 | Screen:Patient-Payer Information ; Field: ‘Accept Assignment’ is true |
| 28 | Total Charge | 2300, CLM, 02 | Claim Amount (Calculated automatically) |
| 29 | Amount Paid | 2300, AMT/F5, 02 | N/A |
| 30 | Reserved NUCC | N/A | N/A |
| 31 | Signature of Physician | 2300, CLM, 06 | Screen:Visit Field: Seen By |
| 32 | Service Address | 2310C, NM1/77, 03 | Screen:Locations ; Field Is service marked ‘true’ |
| 32a | NPI | 2310C, NM1/77, 09 | Screen: Locations; Field: “Group NPI” put in the NPI would like to show on 32a and click ‘use this’ |
| 32b | Reserved NUCC | N/A | N/A |
| 33 | Billing Provider Address Phone | 2010AA, NM1/85, 03 and 04 | Screen: Locations; Field:Is Billing marked ‘true’. |
| 33a | NPI | 2010AA/NM1/85/09 (08=XX) | Screen: User Profile Field: Individual NPI # *Can be overwritten using Locations Group NPI if use 33a is checked |
| 33b | Reserved NUCC | N/A | Screen:User Profile Field: Taxonomy Code |