MCAR HCFA 1500 Instructions

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JE Part B

CMS-1500 Claim Form Crosswalk to EMC Loops and Segments

This crosswalk is not intended to be an all inclusive list of every possible electronic media claim (EMC) loop and segment for a particular item on the paper claim form. Specific questions about loops and segments not indicated in the crosswalk should be referred either to the provider's electronic submitter or our Electronic Data Interchange Support Services (EDISS) department.

For Version 5010A1

Last updated March 17, 2015

CMS-1500 Form Item	CMS-1500 Description	EMC ANSI 837 Loop	EMC ANSI 837 Segments
1	Type of Insurance	2000B	SBR09
1A	Insured's ID Number (HIC)	2010BA	NM109
2	Patient's Name	2010CA	NM103 NM104 NM105 NM107
3	Patient's Birth Date, Sex	2010CA	DMG02 DMG03
4	Insured's Name	2010BA	NM103 NM104 NM105 NM107
5	Patient's Address	2010CA	N302 N401 N402 N403
6	Patient Relationship to Insured	2000B	SBR02
7	Insured's Address	2010BA	N301 N302 N401 N402 N403
8	Patient Status	N/A	N/A
9	Other Insured's Name	2320A	NM103 NM104 NM105 NM107
9A	Other Insured's Policy or Group Number	2320	SBR03
9B	Other Insured's Date of Birth, Sex	N/A	N/A
9C	Employer's or School's Name	N/A	N/A
9D	Insurance Plan Name or Program Name	2320	SBR04
10A	Is Patient's Condition Related to Employment	2300	CLM11
10B	Is Patient's Condition Related to Auto Accident	2300	CLM11
10C	Is Patient's Condition Related to Other Accident	2300	CLM11
10D	Reserved for Local Use	N/A	Not required by Medicare
11	Insured's Policy, Group, or FECA Number	2000B	SBR03
11A	Insured's Date of Birth, Sex	2010BA	DMG02 DMG03
11B	Insured's Employer's or School's Name	N/A	Not required by Medicare
11C	Insurance Plan Name or Program Name	2000B	SBR04
11D	Is there another health benefit plan?	N/A	Not required by Medicare
12	Patient's or Authorized Person's Signature	2300	CLM09
13	Insured's or Authorized Person's Signature	2300	CLM08
14	Date of Current Illness, Injury, Pregnancy	2300	DTP03
15	If Patient Has Had Same or Similar Illness	N/A	Not required by Medicare
16	Dates Patient is Unable to Work in Current Occupation	2300	DTP03
17	Name of Referring/Ordering Provider	2310A (referring) 2420E (ordering) 2310D (supervising)	NM103 NM104 NM105 NM107
17	Qualifier DN = Referring Provider DK = Ordering Provider DQ = Supervising Provider	2310A (referring) 2420E (ordering) 2310D (supervising)	NM101
17A	Other ID#	2310A (referring) 2420E (ordering) 2310D (supervising)	REF02
17B	Referring/Ordering NPI	2310A (referring) 2420E (ordering) 2310D (supervising)	NM109
18	Hospitalization Dates Related to Current Services	2300	DTP03
19	Reserved for Local Use (Commentary and Narrative)	2300	NTE PWK
20	Outside Lab Charges	2400	PS102
21	Diagnosis or Nature of Illness or Injury	2300	HI01-2 through HI12-2
21	ICD Indicator BK – ICD-9 ABK – ICD-10	2300	HI01-1
22	Medicaid Resubmission and/or Original Reference Number	N/A	Not required by Medicare
23	Prior Authorization Number CLIA Number Mammography Certification Number	2300	REF02
24A	Date of Service	2400	DTP03
24B	Place of Service	2300	CLM05-1
24B	Place of Service	2400	SV105
24C	EMG	N/A	Not required by Medicare
24D	Procedure Codes	2400	SV101
24E	Diagnosis Pointer	2400	SV107
24F	$ Charges (Billed Amount)	2400	SV102
24G	Days or Units Billed	2400	SV104
24H	EPSDT/Family Plan	N/A	Not required by Medicare
24I	ID Qualifier	N/A	Leave Blank
24J	Rendering Provider ID # (NPI)	2310B	PRV03 REF02
24J	Rendering Provider ID # (NPI)	2420A	PRV03 REF02
25	Federal Tax ID or SSN	2010AA	REF01 REF02
26	Patient's Account Number	2300	CLM01
27	Accept Assignment	2300	CLM07
28	Total Charge (Billed Amount)	2300	CLM02
29	Amount Paid (by Patient)	2300	AMT02
29	Amount Paid (by Patient)	2320	AMT02
30	Balance Due	N/A	Not required by Medicare
31	Signature of Physician	2300	CLM06
32	Service Facility Location	2310C	NM103 N301 N401 N402 N403
32A	Service Facility NPI	2310C	NM109
32B	Service Facility Other ID#	N/A	Not required by Medicare
33	Billing Provider Info and Phone #	2010AA	NM103 NM104 NM105 NM107 N301 N401 N402 N403 PER04
33A	Billing Provider NPI	2010AA	NM109
33B	Billing Provider Other ID#	N/A	Not required by Medicare
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