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
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- COMPLETION OF CMS-1500 - Full field instruction
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- Medicare provider Enrollment question and answer part 1
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- Complete claim submission - some tips
- Medicare Deductible FAQ
- Secondary claim submission CMS 1500 requirements
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Click the image for see full size sample CMS 1500 claim form. Claim Form Sample