Visual Guide
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1500 Box Number, Elation Billing, and Loop/ Segment Table
1500 Box Number | Title | Location in Elation Billing | 837 Loop | 837 Segment |
1 | Insurance Type, Insured's ID | Insurance Coverage | 200B | SBR09 |
1a | Insured's ID Number | Insurance Coverage | 2010BA | NM109 |
2 | Patient's Name | Patient Demographics | 2010CA or 2010BA | NM103 NM104 NM105 NM107 |
3 | Patient's Birth Date | Patient Demographics | 2010CA or 2010BA | DMG02 DMG03 |
4 | Insured's Name | Insurance Coverage - if different than Patient, found in the Insurance information under "See More" | 2010BA | NM103 NM104 NM105 NM107 |
5 | Patient Address | Patient Demographics | 2010CA | N302 N401 N402 N403 |
6 | Patient Relationship to Insured | Insurance Coverage - "See More" | 2000B or 2000C | SBR02 PAT01 |
7 | Insured's Address, Telephone | Patient Demographics | 2010BA | N301 N302 N401 N402 N403 |
8 | Reserved for NUCC Use - this field is no longer in use | N/A | N/A | N/A |
9 | Other Insured's Name | Secondary Insurance | 2330A | NM103 NM104 NM105 NM107 |
9a | Other Insured's Policy or Group Number | Secondary Insurance | 2320 | SBR03 |
9b, 9c | Reserved for NUCC Use - this field is no longer in use | N/A | N/A | N/A |
9d | Other Insurance Plan Name | Secondary Insurance | 2320 | SBR04 |
10 | Is Patient's Condition Relation To Employment/ Auto Accident/ Other Accident | Superbill - "More Fields" | 2320 2300 | CLM11 HI |
11 | Insured's Policy Group | Insurance Coverage | 2000B 2010BA 2320 | SBR03 DMG02 DMG03 REF01 REF02 SBR04 |
12 | Patient's or Authorized Person's Signature - Information Release | Signature on File - refer to your patient's Intake paperwork | 2300 | CLM09 |
13 | Patient's or Authorized Person's Signature - Payment Authorization | Signature on File - refer to your patient's Intake paperwork | 2300 | CLM08 |
14 | Date of Illness, Injury, Pregnancy | "More Fields" | 2300 | DTP01 DTP03 |
15 | Other Date | Unsupported by Elation Billing - please contact Support | 2300 | DTP01 DTP03 |
16 | Dates Patient Unable To Work In Current Occupation | Unsupported by Elation Billing - please contact Support | 2300 | DTP01 DTP03 |
17 | Referring Provider Name | Superbill - "Add Referring" | 2310A (Referring) 2310D (Supervising) 2420E (Ordering) | NM101 NM103 NM104 NM105 NM107 |
17a | Non-NPI ID | Unsupported by Elation Billing - please contact Support | 2310A (Referring) 2310D (Supervising) 2420E (Ordering) | REF01 REF02 |
17b | Referring NPI | NPI on File | 2310A (Referring) 2310D (Supervising) 2420E (Ordering) | NM109 |
18 | Hospitalization Dates Related to Current Services | Unsupported by Elation Billing - please contact Support | 2300 | DTP03 |
19 | Additional Claim Information | Superbill - "Claim Narrative" | 2300 2310A (Referring) 2310B (Rendering) 2310C (Service Facility) 2310D (Supervising) | NTE PWK REF01 REF02 |
20 | Outside Lab Charges | Unsupported by Elation Billing - please contact Support | 2400 | PS102 |
21 | Diagnoses Codes | Claim Lines - aggregated from all claim lines | 2300 | HI01-2 HI02-2 HI03-2 HI04-2 HI05-2 HI06-2 HI07-2 HI08-2 HI09-2 HI10-2 HI11-2 HI12-2 |
22 | Resubmission Code/ Frequency Code | Superbill - "Corrected Claim Info"
Note - currently only Corrected and Voided codes are accessible within Elation Billing. Please contact Support if you need a different code populated! | 2300 | CLM05-03 REF-2 |
23 | Prior Authorization Number | Superbill - "+ Add Authorization" | 2300 | REF02 |
24a | DOS | Claim Line(s) | 2400 | DTP03 |
24b | POS | Location | 2300 2400
| CLM05-1 SV105 |
24c | EMG | Unsupported by Elation Billing - please contact Support | 2400 | SV109 |
24d | CPTS, Modifiers | Claim Line(s) | 2400 | SV101 (2-6) |
24e | DX Pointer | Claim Line(s) | 2400 | SV107 (1-4) |
24f | Charges | Claim Line(s) | 2400 | SV102 |
24g | Days/ Units | Claim Line(s) | 2400 | SV104 |
24h | EPSDT Family Plan | Unsupported by Elation Billing - please contact Support | 2400 | SV111 SV112
|
24i, 24j | ID. QUAL., Rendering Provider ID | Selected Rendering Provider info (typically Rendering Taxonomy and NPI) - stored in Practice Settings > Providers | 2310B 2420A | PRV02 REF01 NM109 |
25 | Federal Tax ID Number | Practice Settings > Practice Info > EIN | 2010AA | REF01 REF02 |
26 | Patient's Account Number | Superbill ID + your Practice's LMD indicator | 2300 | CLM01 |
27 | Accept Assignment | Default Yes | 2300 | CLM07 |
28 | Total Charge | Total of Charges | 2300 | CLM02 |
29 | Amount Paid | (when submitted to Secondary/ Tertiary) pulled from previous Payments - view via Claim History | 2300 2320 | AMT02 |
30 | Reserved for NUCC Use - this field is no longer in use | N/A | N/A | N/A |
31 | Signature of Physician/ Supplier | Name of Rendering, Date Submitted | 2300 | CLM06 |
32 | Service Facility Location Information | Selected Location - stored in Practice Settings > Service Locations | 2310C
| NM103 N301 N401 N402 N403 NM109 REF01 REF02 |
33 | Billing Provider Info & Phone Number | Practice Settings > Practice Info:
| 2010AA 2000A | NM103 NM104 NM105 NM107 N301 N401 N402 N403 PER04 NM109 PRV03 REF01 REF02 |