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 at this time

2300

DTP01

DTP03

16

Dates Patient Unable To Work In Current Occupation

Unsupported by Elation Billing at this time

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

Superbill - "More Fields"

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 at this time

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 at this time

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"

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 at this time

2400

SV109

24d

CPTS, Modifiers

Claim Line(s)

2400

SV101 (2-7)

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 at this time

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