The shaded fields in boxes 17a, 24I, 24J, 32b and 33b should be used to report provider numbers other than the NPI as needed. Fields 17a and 24I include a separate space for a two-digit qualifier that describes the type of identifier entered. (See “Two-digit qualifiers” for a list.) Fields 32b and 33b do not have a separate area for the qualifiers, but the qualifier should still be the first two digits entered.
These two-digit qualifiers should be used as appropriate in fields 17a, 24I, 32b and 33b of the revised 1500 claim form.
0B State license number
1B Blue Shield provider number
1C Medicare provider number
1D Medicaid provider number
1G Provider UPIN
1H CHAMPUS identification number
EI Employer’s identification number
G2 Provider commercial number
LU Location number
N5 Provider plan network identification number
SY Social Security number (This may not be used for Medicare.)
X5 State industrial accident provider number
ZZ Provider taxonomy
The following identifiers are to be used when reporting services related to them.
ZZ Narrative description of unspecified code
N4 National Drug Codes (NDC)
VP Vendor product number Health Industry Business Communications Council (HIBCC) labeling standard
OZ Product number Health Care Uniform Code Council – Global Trade Item Number (GTIN)
CTR Contract rate
Related Links :
- CMS 1500 claim form - How to fill out correctly - Instruction
- Referring provider, Ordering provider and billing ...
- Medicare provider Enrollment question and answer part 1
- Medicare Enrollment - question and answer part 2
- Complete claim submission - some tips
- Medicare Deductible FAQ
- Secondary claim submission CMS 1500 requirements
- UB 04 - Complete instruction to fill the form
The other ID number of the referring provider, ordering provider, or other source should be reported in 17a in the shaded area. The qualifie...
Item 17 Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicia...
For Adjustments: When requesting an adjustment to a paid claim, enter an “A” followed by the 13-character internal control number (ICN) as...
Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), al...
Bottom section of the CMS 1500 form Supplemental information Shaded line �� In the shaded area across Fields 24A through 24H, enter s...
Billing instruction for Ambulance Billing - Box 20 to 23 BlockNo. Block Name Block Code Notes ...
When submitting attachments with the CMS-1500 claim form, please follow these guidelines: Any attachment should be marked with the benef...
Click the image for see full size sample CMS 1500 claim form. Claim Form Sample
TWO-DIGIT QUALIFIERS The shaded fields in boxes 17a, 24I, 24J, 32b and 33b should be used to report provider numbers other than the NPI as...