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

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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 (Medicare ID)
  • 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

 

Last Updated Oct 23, 2018