Blocks Description Loops Segments Qualifiers
1a Insured’s ID number 2010BA NM1 MI
2 Patient’s name 2010BA NM1 IL
5 Patient’s address 2010BA N3,N4 none
9 Other insured’s name 2330A NM1 IL
12 Patient or authorized person’s signature 2300 CLM none
13 Insured or authorized person’s signature 2300 CLM none
14 Date of current illness 2300 DTP 431
15 Same or similar illness 2300 DTP 438
17 Name of referring 2310A NM1 DN
17b NPI 2310A NM1 XX
18 Hospitalization dates related to
current services-Admission 2300 DTP 435
18 Hospitalization dates related to current
services-Discharge 2300 DTP 96
19 Reserved for Local Use 2300 NTE ADD
19 Drug Identification for the NDC number 2410 LIN none
19 Drug Pricing Unit Price, Quantity,
Unit of Measure 2410 CTP none
20 Outside Lab 2400 PS1 none
21 Diagnosis or Nature of Illness or Injury 2300 HI BK, BF
24a Date of service 2400 DTP 472
24b Place of Service 2400 CLM none
24d Procedure (HCPCS) 2400 SV1 HC
24d Modifier 2400 SV1 none
24e Diagnosis pointer 2400 SV1 none
24f Charges 2400 SV1 none
24g Days or units 2400 SV1 UN
24j Rendering provider ID# 2310B NM1 82
25 Federal tax ID number/SSN 2010AA REF EI/SY
26 Patient’s account number 2300 CLM none
27 Accept assignment 2300 CLM none
28 Total charge 2300 CLM none
29 Amount paid 2300 AMT F5
32 Service facility location 2310D NM1 FA
32 Service facility address 2310D N3,N4 none
33 Billing provider name 2010AA NM1 85
33 Billing provider address 2010AA N3,N4 none
33 Billing provider phone number 2010AA PER none
