CMS-1500 Paper Claim Form Crosswalk to EMC Loops and Segments - 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. Users may refer to Noridian’s Claim Form Instructions for how to complete each claim field.
For Version 5010A1
| CMS-1500 Form Item | CMS-1500 Description | EMC ANSI 837 Loop | EMC ANSI 837 Segments |
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| 1 | Type of Insurance |
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| 1A | Insured's ID Number (Medicare ID) |
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| 2 | Patient's Name |
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| 3 | Patient's Birth Date, Sex |
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| 4 | Insured's Name |
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| 5 | Patient's Address |
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| 6 | Patient Relationship to Insured |
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| 7 | Insured's Address |
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| 8 | Patient Status |
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| 9 | Other Insured's Name |
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| 9A | Other Insured's Policy or Group Number |
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| 9B | Other Insured's Date of Birth, Sex |
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| 9C | Employer's or School's Name |
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| 9D | Insurance Plan Name or Program Name |
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| 10A | Is Patient's Condition Related to Employment |
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| 10B | Is Patient's Condition Related to Auto Accident |
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| 10C | Is Patient's Condition Related to Other Accident |
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| 10D | Reserved for Local Use |
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| 11 | Insured's Policy, Group, or FECA Number |
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| 11A | Insured's Date of Birth, Sex |
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| 11B | Insured's Employer's or School's Name |
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| 11C | Insurance Plan Name or Program Name |
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| 11D | Is there another health benefit plan? |
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| 12 | Patient's or Authorized Person's Signature |
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| 13 | Insured's or Authorized Person's Signature |
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| 14 | Date of Current Illness, Injury, Pregnancy |
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| 15 | If Patient Has Had Same or Similar Illness |
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| 16 | Dates Patient is Unable to Work in Current Occupation |
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| 17 | Name of Referring/Ordering Provider |
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| 17 | Qualifier
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| 17A | Other ID# |
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| 17B | Referring/Ordering NPI |
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| 18 | Hospitalization Dates Related to Current Services |
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| 19 | Reserved for Local Use (Commentary and Narrative) |
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| 20 | Outside Lab Charges |
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| 21 | Diagnosis or Nature of Illness or Injury |
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| 21 | ICD Indicator
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| 22 | Medicaid Resubmission and/or Original Reference Number |
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| 23 | Prior Authorization Number CLIA Number Mammography Certification Number |
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| 24A | Date of Service |
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| 24B | Place of Service |
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| 24B | Place of Service |
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| 24C | EMG |
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| 24D | Procedure Codes |
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| 24E | Diagnosis Pointer |
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| 24F | $ Charges (Billed Amount) |
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| 24G | Days or Units Billed |
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| 24H | EPSDT/Family Plan |
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| 24I | ID Qualifier |
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| 24J | Rendering Provider ID # (NPI) |
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| 24J | Rendering Provider ID # (NPI) |
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| 25 | Federal Tax ID or SSN |
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| 26 | Patient's Account Number |
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| 27 | Accept Assignment |
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| 28 | Total Charge (Billed Amount) |
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| 29 | Amount Paid (by Patient) |
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| 29 | Amount Paid (by Patient) |
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| 30 | Balance Due |
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| 31 | Signature of Physician |
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| 32 | Service Facility Location |
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| 32A | Service Facility NPI |
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| 32B | Service Facility Other ID# |
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| 33 | Billing Provider Info and Phone # |
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| 33A | Billing Provider NPI |
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| 33B | Billing Provider Other ID# |
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Last Updated Apr 23 , 2024
