Item

Field Description

Instructions

Item 0

Carrier Block

Enter in the white, open carrier area the name and address of the payer to whom this claim is being sent. Enter the name and address information in the following format:

1st Line – Name

2nd Line – First line of address

3rd Line – Second line of address, if necessary

4th Line – City, State (2 characters) and ZIP code

Item 1

Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other

Indicate the type of health insurance coverage applicable to this claim by placing an X in the appropriate box. Only one box can be marked.

Item 1a

Insured's ID Number

Enter the appropriate identifier of the employee.

Item 2

Patient's Name

Enter the patient’s full last name, first name, and middle initial. If the patient uses a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.

Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.

If the patient’s name is the same as the insured’s name (i.e., the patient is the insured), then it is not necessary to report the patient’s name.

Item 3

Patient's Birth Date and Sex

Enter the patient’s 8-digit birth date (MM | DD | YYYY). Enter an X in the correct box to indicate sex (gender) of the patient. Only one box can be marked. If sex is unknown, leave blank.

Item 4

Insured's Name

Enter the name of the Employer.

Item 5

Patient’s Address (multiple fields)

Enter the patient’s address.

The first line is for the street address;

the second line, the city and state;

the third line, the ZIP code.

Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Report a 5 or 9-digit ZIP code. Enter the 9-digit ZIP code without the hyphen.

If reporting a foreign address, contact payer for specific reporting instructions.

If the patient’s address is the same as the insured’s address, then it is not necessary to report the patient’s address.

“Patient’s Telephone” does not exist in 5010A1. The NUCC recommends that the phone number not be reported. Phone extensions are not supported.

If required by a payer to report a telephone number, do not use a hyphen or space as a separator within the telephone number.

Item 6

Patient's Relationship to Insured

Enter an X in the correct box to indicate the patient’s relationship to insured when Item Number 4 is completed. Only one box can be marked.

If the patient is a dependent, but has a unique Member Identification Number and the payer requires the identification number be reported on the claim, then report “Self”, since the patient is reported as the insured.

Item 7

Insured’s Address (multiple fields)

Enter the address of the Employer. If Item Number 4 is completed, then this field should be completed.

The first line is for the street address;

the second line, the city and state;

the third line, the ZIP code.

Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Report a 5 or 9-digit ZIP code. Enter the 9-digit ZIP code without the hyphen.

If reporting a foreign address, contact payer for specific reporting instructions.

“Insured’s Telephone” does not exist in 5010A1. The NUCC recommends that the phone number not be reported. Phone extensions are not supported. If required by a payer to report a telephone number, do not use a hyphen or space as a separator within the telephone number.

Item 8

Reserved for NUCC Use

Leave blank.

Item 9

Other Insured’s Name

If Item Number 11d is marked, complete fields 9, 9a, and 9d, otherwise leave blank. When additional group health coverage exists, enter other insured’s full last name, first name, and middle initial of the enrollee in another health plan if it is different from that shown in Item Number 2. If the insured uses a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name.

Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.

Item 9a

Other Insured’s Policy or Group Number

Enter the policy or group number of the other insured.

Do not use a hyphen or space as a separator within the policy or group number

Item 9b

Reserved for NUCC Use

Leave blank.

Item 9c

Reserved for NUCC Use

Leave blank.

Item 9d

Insurance Plan Name or Program Name

Enter the other insured’s insurance plan or program name.

Items 10a–10c

Is Patient’s Condition Related To:

When appropriate, enter an X in the correct box to indicate whether one or more of the services described in Item Number 24 are for a condition or injury that occurred on the job or as a result of an automobile or other accident. Only one box on each line can be marked.

The state postal code where the accident occurred must be reported 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 Number 11.

Item 10d

Claim Codes (Designated by NUCC)

Condition Codes are required when submitting a bill that is a duplicate or an appeal. (Original Reference Number must be entered in Box 22 for these situations). Note: Do not use Condition Codes when submitting a revised or corrected bill.

When applicable, use to report appropriate claim codes. Applicable claim codes are

designated by the NUCC. Please refer to the most current instructions from the public or private payer

regarding the need to report claim codes.

When required by payers to provide the sub-set of Condition Codes approved by the NUCC, enter the

Condition Code in this field. The Condition Codes approved for use on the 1500 Claim Form are

available at www.nucc.org under Code Sets.

When reporting more than one code, enter three blank spaces and then the next code

Item

Field Description

Instructions

Item 11

Insured’s Policy, Group, or FECA Number

Enter the insured’s policy or group number as it appears on the insured’s health care identification card. If Item Number 4 is completed, then this field should be completed.

Do not use a hyphen or space as a separator within the policy or group number

Item 11a

Insured's Date of Birth and Sex

Enter the 8-digit date of birth (MM│DD│YYYY) of the insured and an X to indicate the sex (gender) of the insured. Only one box can be marked. If gender is unknown, leave blank. (For workers' compensation this is usually not required.)

Item 11b

Other Claim ID (Designated by NUCC)

Required if known. Enter the claim number assigned by the payer.

Item 11c

Insurance Plan Name or Program Name

Enter the name of the insurance plan or program of the insured. Some payers require an identification number of the primary insurer rather than the name in this field.

Item 11d

Is there another Health Benefit Plan?

When appropriate, enter an X in the correct box. If marked “YES”, complete 9, 9a, and 9d. Only one box can be marked.

Item 12

Patient's or Authorized Person's Signature

Enter “Signature on File,” “SOF,” or legal signature. When legal signature, enter date signed in 6-digit (MM|DD|YY) or 8-digit format (MM|DD|YYYY) format. If there is no signature on file, leave blank or enter “No Signature on File.”

Item 13

Insured’s or Authorized Person’s Signature

Enter “Signature on File,” “SOF,” or legal signature. If there is no signature on file, leave blank or enter “No Signature on File.” (For workers' compensation this is usually not required.)

Item 14

Date of Current Illness, Injury, or Pregnancy (LMP)

Enter the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date of the first date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date.

Enter the applicable qualifier to identify which date is being reported.

431 Onset of Current Symptoms or Illness

484 Last Menstrual Period

Enter the qualifier to the right of the vertical, dotted line.

Item 15

Other Date

Enter another date related to the patient’s condition or treatment. Enter the date in the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) format. Enter the applicable qualifier to identify which date is being reported.

454 Initial Treatment

304 Latest Visit or Consultation

453 Acute Manifestation of a Chronic Condition

439 Accident

455 Last X-ray

471 Prescription

090 Report Start (Assumed Care Date)

091 Report End (Relinquished Care Date)

444 First Visit or Consultation

Enter the qualifier between the left-hand set of vertical, dotted lines.

Item 16

Dates Patient Unable to Work in Current Occupation

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 must be shown for the “from–to” dates that the patient is unable to work. An entry in this field may indicate employment-related insurance coverage.

Item 17

Name of Referring Provider or Other Source

Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim.

If multiple providers are involved, enter one provider using the following priority order:

1. Referring Provider

2. Ordering Provider

3. Supervising Provider

Do not use periods or commas. A hyphen can be used for hyphenated names.

Enter the applicable qualifier to identify which provider is being reported.

DN Referring Provider

DK Ordering Provider

DQ Supervising Provider

Enter the qualifier to the left of the vertical, dotted line.

Item 17a

Other ID#

The Other ID number of the referring, ordering, or supervising provider is reported in 17a in the shaded area. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a.

The NUCC defines the following qualifiers used in 5010A1:

0B State License Number

1G Provider UPIN Number

G2 Provider Commercial Number

LU Location Number (This qualifier is used for Supervising Provider only.)

Item 17b

NPI #

Enter the NPI number of the referring, ordering, or supervising provider in Item Number 17b.

Item 18

Hospitalization Dates Related to Current Services

Enter the inpatient 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) hospital admission date followed by the discharge date (if discharge has occurred). If not discharged, leave discharge date blank. This date is when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

Item 19

Additional Claim Information (Designated by NUCC)

Please refer to the most current instructions from the public or private payer regarding the use of this field. Report the appropriate qualifier, when available, for the information being entered. Do not enter a space, hyphen, or other separator between the qualifier and the information.

For the Claim Information (NTE), the following are the qualifiers in 5010A1. Enter the qualifier “NTE”, followed by the appropriate qualifier, then the information. Do not enter spaces between the qualifier and the first word of the information. After the qualifier, use spaces to separate any words.

ADD Additional Information

CER Certification Narrative

DCP Goals, Rehabilitation Potential, or Discharge Plans

DGN Diagnosis Description

TPO Third Party Organization Notes

For additional identifiers (REFs), the following are the qualifiers in 5010A1. Enter the qualifier “REF”, followed by the qualifier, then the identifier. Do not enter spaces between the qualifier and identifier.

0B State License Number

1G Provider UPIN Number

G2 Provider Commercial Number

LU Location Number (This qualifier is used for Supervising Provider only.)

N5 Provider Plan Network Identification Number

SY Social Security Number (The social security number may not be used for Medicare.)

X5 State Industrial Accident Provider Number

ZZ Provider Taxonomy (The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ

will remain the qualifier for the 1500 Claim Form.)

The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identifiers are assigned to the provider either by a specific payer or by a third party in order to uniquely identify the provider. The taxonomy code is designated by the provider in order to identify his/her provider grouping, classification, or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.

Taxonomy codes or other identifiers reported in this field must not be reportable in other fields, i.e.,Item Numbers 17, 24J, 32, or 33.

For Supplemental Claim Information (PWK), the following are the qualifiers in the 5010A1. Enter the qualifier “PWK”, followed by the appropriate Report Type Code, the appropriate Transmission Type Code, then the Attachment Control Number. Do not enter spaces between the qualifiers and data.

REPORT TYPE CODES

03 Report Justifying Treatment Beyond Utilization

04 Drugs Administered

05 Treatment Diagnosis

06 Initial Assessment

07 Functional Goals

08 Plan of Treatment

09 Progress Report

10 Continued Treatment

11 Chemical Analysis

13 Certified Test Report

15 Justification for Admission

21 Recovery Plan

A3 Allergies/Sensitivities Document

A4 Autopsy Report

AM Ambulance Certification

AS Admission Summary

B2 Prescription

B3 Physician Order

B4 Referral Form

BR Benchmark Testing Results

BS Baseline

BT Blanket Test Results

CB Chiropractic Justification

CK Consent Form(s)

CT Certification

D2 Drug Profile Document

DA Dental Models

DB Durable Medical Equipment Prescription

DG Diagnostic Report

DJ Discharge Monitoring Report

DS Discharge Summary

EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)

HC Health Certificate

HR Health Clinic Records

I5 Immunization Record

IR State School Immunization Records

LA Laboratory Results

M1 Medical Record Attachment

MT Models

NN Nursing Notes

OB Operative Note

OC Oxygen Content Averaging Report

OD Orders and Treatments Document

OE Objective Physical Examination (including vital signs) Document

OX Oxygen Therapy Certification

OZ Support Data for Claim

P4 Pathology Report

P5 Patient Medical History Document

PE Parenteral or Enteral Certification

PN Physical Therapy Notes

PO Prosthetics or Orthotic Certification

PQ Paramedical Results

PY Physician’s Report

PZ Physical Therapy Certification

RB Radiology Films

RR Radiology Reports

RT Report of Tests and Analysis Report

RX Renewable Oxygen Content Averaging Report

SG Symptoms Document

V5 Death Notification

XP Photographs

TRANSMISSION TYPE CODES

AA Available on Request at Provider Site

BM By Mail

When reporting multiple separate items, enter three blank spaces and then the next qualifier and followed by the information

Item 20

Outside Lab? $Charges

Complete this field when billing for purchased services by entering an X in “YES.” A “YES” mark indicates that the reported service was provided by an entity other than the billing provider (for example, services subject to Medicare’s anti-markup rule). A “NO” mark or blank indicates that no purchased services are included on the claim.

If “YES” is marked, enter the purchase price under “$Charges” and complete Item Number 32. Each purchased service must be reported on a separate claim form as only one charge can be entered.

When entering the charge amount, enter the amount in the field to the left of the vertical line. Enter number right justified to the left of the vertical line. Enter 00 for cents if the amount is a whole number. Do not use dollar signs, commas, or a decimal point when reporting amounts. Negative dollar amounts are not allowed. Leave the right-hand field blank.

Item

Field Description

Instructions

Item 21

Diagnosis or Nature of Illness or Injury

Enter the applicable ICD indicator to identify which version of ICD codes is being reported.

9 ICD-9-CM

0 ICD-10-CM

Enter the indicator between the vertical, dotted lines in the upper right-hand area of the field.

Enter the codes left justified on each line to identify the patient’s diagnosis or condition. Do not include the decimal point in the diagnosis code, because it is implied. List no more than 12 ICD-10-CM or ICD-9- CM diagnosis codes. Relate lines A - L to the lines of service in 24E by the letter of the line. Use the greatest level of specificity. Do not provide narrative description in this field.

Item 22

Resubmission and/or Original Reference Number

List the original reference number for resubmitted claims. Please refer to the most current instructions from the public or private payer regarding the use of this field.

When resubmitting a claim, enter the appropriate bill frequency code left justified in the left-hand side of the field.

7 Replacement of prior claim

8 Void/cancel of prior claim

This Item Number is not intended for use for original claim submissions.

Item 23

Prior Authorization Number

Enter any of the following: prior authorization number, referral number, mammography pre-certification number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service.

Do not enter hyphens or spaces within the number.

Item 24

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 identifier and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service.

The supplemental information is to be placed in the shaded section of 24A through 24G as defined in each Item Number. Providers must verify requirements for this supplemental information with the payer.

Item 24A

Date(s) of Service [lines 1–6]

Enter date(s) of service, both the “From” and “To” dates. If there is only one date of service, enter that date under “From.” Leave “To” blank or re-enter “From” date. If grouping services, the place of service, procedure code, charges, and individual provider for each line must be identical for that service line. Grouping is allowed only for services on consecutive days. The number of days must correspond to the number of units in 24G.

When required by payers to provide additional narrative description of an unspecified code, NDC, contract rate, or tooth numbers and areas of the oral cavity enter the applicable qualifier and number/code/information starting with the first space in the shaded line of this field. Do not enter a space, hyphen, or other separator between the qualifier and the number/code/ information. The information may extend to 24G.

Item 24B

Place of Service [lines 1–6]

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 Codes are available at: www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html.

Item 24C

EMG [lines 1–6]

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. The definition of emergency would be either defined by federal or state regulations or programs, payer contracts, or as defined in 5010A1.

Item 24D

Procedures, Services, or Supplies [lines 1–6]

Enter the CPT or HCPCS code(s) and modifier(s) (if applicable) from the appropriate code set in effect on the date of service. This field accommodates the entry of up to four 2-character modifiers. The specific procedure code(s) must be shown without a narrative description.

Item 24E

Diagnosis Pointer [lines 1–6]

In 24E, enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A – L or multiple letters as applicable. ICD-10-CM or ICD-9-CM diagnosis codes must be entered in Item Number 21. Do not enter them in 24E.

Enter letters left justified in the field. Do not use commas between the letters.

Item 24F

$Charges [lines 1–6]

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. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the right-hand area of the field if the amount is a whole number.

Item 24G

Days or Units [lines 1–6]

Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered.

Enter numbers left justified in the field. No leading zeros are required. If reporting a fraction of a unit, use the decimal point.

Anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period (such as “daily management”).

Item 24H

EPSDT/Family Plan [lines 1–6]

(For workers' compensation this is usually not required.)

For reporting of Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) and Family Planning services, refer to specific payer instructions.

EPSDT: When EPSDT services are reported on this claim, identify the status of the referral by entering one of the following reason codes right justified in the shaded area of the field.

The following codes for EPSDT are used in 5010A1:

AV Available – Not Used (Patient refused referral.)

S2 Under Treatment (Patient is currently under treatment for referred diagnostic or corrective health problem.)

ST New Service Requested (Referral to another provider for diagnostic or corrective treatment/scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service, not including dental referrals.)

NU Not Used (Used when no EPSDT patient referral was given.)

Family Planning: When there is a requirement to report this is a Family Planning service, enter Y for “YES” in the unshaded area of the field.

When there is no requirement to report this is a Family Planning service, leave the field blank.

Item 24I

ID Qualifier [lines 1–6]

Enter in the shaded area of 24I the qualifier identifying if the number is a non-NPI. The Other ID# of the rendering provider should be reported in 24J in the shaded area.

The NUCC defines the following qualifiers used in 5010A1:

0B State License Number

1G Provider UPIN Number

G2 Provider Commercial Number

LU Location Number

ZZ Provider Taxonomy (The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ will remain the qualifier for the 1500 Claim Form.)

The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identifiers are assigned to the provider either by a specific payer or by a third party in order to uniquely identify the provider. The taxonomy code is designated by the provider in order to identify his/her provider grouping, classification, or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.

The Rendering Provider is the person or company (laboratory or other facility) who rendered or supervised the care. In the case where a substitute provider (locum tenens) was used, enter that provider’s information here. Report the Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b.

Item 24J

Rendering Provider ID # [lines 1–6]

The individual rendering the service is reported in 24J. Enter the non-NPI ID number in the shaded area of the field. Enter the NPI number in the unshaded area of the field.

The Rendering Provider is the person or company (laboratory or other facility) who rendered or supervised the care. In the case where a substitute provider (locum tenens) was used, enter that provider’s information here. Report the Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b.

Enter numbers left justified in the field.

Item 25

Federal Tax ID Number

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 number intended to be used for 1099 reporting purposes. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked.

Do not enter hyphens with numbers. Enter numbers left justified in the field.

Item 26

Patient's Account Number

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 justified in the field

Item 27

Accept Assignment?

Enter an X in the correct box. Only one box can be marked.

Report “Accept Assignment?” for all payers.

Item 28

Total Charge

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. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the amount is a whole number

Item 29

Amount Paid

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. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the right-hand area if the amount is a whole number.

Item 30

Reserved for NUCC Use

Leave blank.

Item 31

Signature of Physician or Supplier Including Degrees or Credentials

“Signature of Physician or Supplier Including Degrees or Credential” does not exist in 5010A1.

Enter the legal signature of the practitioner or supplier, signature of the practitioner or supplier representative, “Signature on File,” or “SOF.” Enter either the 6-digit date (MM|DD|YY), 8-digit date (MM|DD|YYYY), or alphanumeric date (e.g., January 1, 2003) the form was signed.

Item 32

Service Facility Location Information

Enter the name, address, city, state, and ZIP code of the location where the services were rendered. Providers of service (namely physicians) must identify the supplier’s name, address, ZIP code, and NPI number when billing for purchased diagnostic tests. When more than one supplier is used, a separate 1500 Claim Form should be used to bill for each supplier.

If the “Service Facility Location” is a component or subpart of the Billing Provider and they have their own NPI that is reported on the claim, then the subpart is reported as the Billing Provider and “Service Facility Location” is not used. When reporting an NPI in the “Service Facility Location,” the entity must be an external organization to the Billing Provider.

Enter the name and address information in the following format:

1st Line – Name

2nd Line – Address

3rd Line – City, State and ZIP code

Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between town name and state code; do not include a comma. Report a 9-digit ZIP code. Enter the 9-digit ZIP code without the hyphen.

If reporting a foreign address, contact payer for specific reporting instructions.

Item 32a

NPI#

Enter the NPI number of the service facility location in 32a.

Only report a Service Facility Location NPI when the NPI is different from the Billing Provider NPI.

Item 32b

Other ID#

Enter the qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.

The NUCC defines the following qualifiers used in 5010A1:

0B State License Number

G2 Provider Commercial Number

LU Location Number

Item 33

Billing Provider Info & Ph #

Enter the provider’s or supplier’s billing name, address, ZIP code, and phone number. The phone number is to be entered in the area to the right of the field title. Enter the name and address information in the following format:

1st Line – Name

2nd Line – Address

3rd Line – City, State and ZIP code

Item 33 identifies the provider that is requesting to be paid for the services rendered and should always be completed.

Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between town name and state code; do not include a comma. Report a 9-digit ZIP code. Enter the 9-digit ZIP code without the hyphen. Do not use a hyphen or space as a separator within the telephone number.

If reporting a foreign address, contact payer for specific reporting instructions.

5010A1 requires the “Billing Provider Address” be a street address or physical location. The NUCC recommends that the same requirements be applied here.

Item 33a

NPI#

Enter the NPI number of the billing provider in 33a.

Item 33b

Other ID#

Enter the qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.

The NUCC defines the following qualifiers used in 5010A1:

0B State License Number

G2 Provider Commercial Number

ZZ Provider Taxonomy (The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ will remain the qualifier for the 1500 Claim Form.)

The above list contains both provider identifiers, as well as the provider taxonomy code. The provider identifiers are assigned to the provider either by a specific payer or by a third party in order to uniquely identify the provider. The taxonomy code is designated by the provider in order to identify his/her provider grouping, classification, or area of specialization. Both, provider identifiers and provider taxonomy may be used in this field.