Fields 14-33 - Provider of Service or Supplier Information
FIELD 33, 33a, AND 33b- Billing Provider Info & Phone Number
The billing provider’s or supplier’s billing name, address, ZIP code, and phone number is the billing office location and telephone number of the provider or supplier. NUCC INSTRUCTIONS: Field 33 -Enter the provider’s or supplier’s billing name, ...
FIELD 32, 32a, AND 32b- Service Facility Location Information
The name and address of facility where services were rendered identifies the site where service(s) were provided. NUCC INSTRUCTIONS: Enter the name, address, city, state, and ZIP code of the location where the services were rendered. Providers of ...
FIELD 31- Signature of Physician or Supplier Including Degrees or Credentials
The “Signature of the Physician or Supplier Including Degrees or Credentials” refers to the authorized or accountable person and the degree, credentials, or title. NUCC INSTRUCTIONS: “Signature of Physician or Supplier Including Degrees or ...
FIELD 30- Reserved for NUCC Use
This field is reserved for NUCC use. NUCC INSTRUCTIONS: This field was previously used to report “Balance Due.” “Balance Due” does not exist in 5010A1, so this field has been eliminated. This field is reserved for NUCC use. The NUCC will provide ...
FIELD 29- Amount Paid
The “Amount Paid” is the payment received from the patient or other payers NUCC INSTRUCTIONS: Enter total amount the patient and/or other payers paid on the covered services only. Enter the amount right justified in the left-hand area of the field. ...
FIELD 28- Total Charge
The “Total Charge” is the total billed amount for all services entered in 24F (lines 1–6). NUCC INSTRUCTIONS: Enter total charges for the services (i.e., total of all charges in 24F). Enter the amount right justified in the dollar area of the field. ...
FIELD 27- Accept Assignment?
The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer’s program. NUCC INSTRUCTIONS: Enter an X in the correct box. Only one box can be marked. Report “Accept Assignment?” for all payers. MEDICARE ...
FIELD 26- Patient’s Account No.
The “Patient’s Account No.” is the identifier assigned by the provider. NUCC INSTRUCTIONS: Enter the patient’s account number assigned by the provider of service’s or supplier’s accounting system. Do not enter hyphens with numbers. Enter numbers left ...
FIELD 25- Federal Tax ID Number
The “Federal Tax ID Number” is the unique identifier assigned by a federal or state agency. NUCC INSTRUCTIONS: Enter the “Federal Tax ID Number” (employer ID number or SSN) of the Billing Provider identified in Item Number 33. This is the tax ID ...
FIELD 24J- Rendering Provider ID # [lines 1–6]
The individual performing/rendering the service should be reported in 24J and the qualifier indicating if the number is a non-NPI is reported in 24I. The non-NPI ID number of the rendering provider refers to the payer assigned unique identifier of ...
FIELD 24I- ID Qualifier [lines 1–6]
If the provider does not have an NPI number, enter the appropriate qualifier and identifying number in the shaded area. There will always be providers who do not have an NPI and will need to report non-NPI identifiers on their claim forms. The ...
FIELD 24H- EPSDT/Family Plan [lines 1–6]
The “EPSDT/Family Plan” identifies certain services that may be covered under some state plans. NUCC INSTRUCTIONS: For reporting of Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) and Family Planning services, refer to specific payer ...
FIELD 24G- Days or Units [lines 1–6]
“Days or Units” is the number of days corresponding to the dates entered in 24A or units as defined in CPT or HCPCS coding manual(s). NUCC INSTRUCTIONS: Enter the number of days or units. This field is most commonly used for multiple visits, units of ...
FIELD 24F - $Charges [lines 1–6]
“$Charges” is the total billed amount for each service line. NUCC INSTRUCTIONS: Enter the charge amount for each listed service. Enter the number right justified in the left-hand area of the field. Do not use commas when reporting dollar amounts. ...
FIELD 24E - Diagnosis Pointer [lines 1–6]
The “Diagnosis Pointer” is the line letter from Item Number 21 that relates to the reason the service(s) was performed. NUCC INSTRUCTIONS: In 24E, enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate the date of ...
FIELD 24D - Procedures, Services, or Supplies [lines 1–6]
“Procedures, Services or Supplies” identify the medical services and procedures provided to the patient. NUCC INSTRUCTIONS: Enter the CPT or HCPCS code(s) and modifier(s) (if applicable) from the appropriate code set in effect on the date of service. ...
FIELD 24C - EMG [lines 1–6]
“EMG” identifies if the service was an emergency. NUCC INSTRUCTIONS: Check with payer to determine if this information (emergency indicator) is necessary. If required, enter Y for “YES” or leave blank if “NO” in the bottom, unshaded area of the ...
FIELD 24B - Place of Service [lines 1–6]
The “Place of Service” Code identifies the location where the service was rendered. NUCC INSTRUCTIONS: In 24B, enter the appropriate two-digit code from the Place of Service Code list for each item used or service performed. The Place of Service ...
Field 24a - Date(s) of Service [lines 1–6]
“Date(s) of Service” indicates the actual month, day, and year the service(s) was provided. Grouping services refers to a charge for a series of identical services without listing each date of service. NUCC INSTRUCTIONS: Enter date(s) of service, ...
Section 24
NUCC INSTRUCTIONS: Supplemental information can only be entered with a corresponding, completed service line. The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and another/proprietary ...
Field 23 - Prior Authorization Number
The “Prior Authorization Number” is the payer assigned number authorizing the service(s). NUCC INSTRUCTIONS: Enter any of the following: prior authorization number, referral number, mammography certification number, or Clinical Laboratory Improvement ...
Field 22 - Resubmission and/or Original Reference Number
“Resubmission” means the code and original reference number assigned by the destination payer or receiver to indicate a previously submitted claim or encounter. NUCC INSTRUCTIONS: List the original reference number for resubmitted claims. Please ...
Field 21 - Diagnosis or Nature of Illness or Injury
The “ICD Indicator” identifies the version of the ICD code set being reported. The “Diagnosis or Nature of Illness or Injury” is the sign, symptom, complaint, or condition of the patient relating to the service(s) on the claim. NUCC ...
Field 20 - Outside Lab? $Charges
“Outside lab? $Charges” indicates that services have been rendered by an independent provider as indicated in Item Number 32 and the related costs. NUCC INSTRUCTIONS: Complete this field when billing for purchased services by entering an X in “YES.” ...
Field 19 - Additional Claim Information (Designated by NUCC)
“Additional Claim Information” identifies additional information about the patient’s condition or the claim. NUCC INSTRUCTIONS: Please refer to the most current instructions from the public or private payer regarding the use of this field. Report the ...
Field 18 - Hospitalization Dates Related to Current Services
The “Hospitalization Dates Related to Current Services” refers to an inpatient stay and indicates the admission and discharge dates associated with the service(s) on the claim. NUCC INSTRUCTIONS: Enter the inpatient 6-digit (MM│DD│YY) or 8-digit ...
Field 17a - Other ID and 17b - NPI number
17a - The non-NPI ID number of the referring, ordering, or supervising provider is the unique identifier of the professional. 17b - The NPI number refers to the HIPAA National Provider Identifier number. NUCC INSTRUCTIONS: 17a -The Other ID number of ...
Field 17 - Name of Referring Provider or Other Source
The name entered is the referring provider, ordering provider, or supervising provider who referred, ordered, or supervised the service(s) or supply(ies) on the claim. The qualifier indicates the role of the provider being reported. NUCC ...
Field 16 - Dates Patient Unable to Work in Current Occupation
“Dates Patient Unable to Work in Current Occupation” is the time span the patient is or was unable to work. NUCC INSTRUCTIONS: If the patient is employed and is unable to work in current occupation, a 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date ...
Field 15 - Other Date
The “Other Date” identifies additional date information about the patient’s condition or treatment. NUCC INSTRUCTIONS: Enter another date related to the patient’s condition or treatment. Enter the date in the 6-digit (MM│DD│YY) or 8-digit ...
Field 14 - Date of Current Illness, Injury, or Pregnancy (LMP)
The “Date of Current Illness, Injury, or Pregnancy” identifies the first date of onset of illness, the actual date of injury, or the LMP for pregnancy. NUCC INSTRUCTIONS: Enter the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date of the first date of ...