C.M.R. 90, 590, ch. 243, app 590-243-G-2
Data Element # | Data Element Name | UB-04 Form Locator | CMS 1500 # | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop Segment ID/Code Value/ Reference Designator |
CF001 | Submitter | N/A | N/A | N/A |
CF002 | Payor | N/A | N/A | N/A |
CF003 | Insurance Type/Product Code | N/A | N/A | 835/2100/CLP/06 |
CF004 | Subscriber Social Security Number | N/A | N/A | 835/2100/NM1/MI/09 |
CF005 | Member Identification Code | N/A | N/A | 835/2100/NM1/34/09 |
CF006 | Plan Specific Contract Number | 60 (A-C) | 1a | 835/2100/NM1/MI/09 |
CF007 | Member Suffix or Sequence Number | N/A | N/A | N/A |
CF008 | Carrier Specific Unique Member (CSUM) ID | N/A | N/A | N/A |
CF009 | Insured Group or Policy Number | 62 (A-C) | 11 | 837/2000B/SBR/03 |
CF010 | Monetary Amount/Provider Adjustment Amount | N/A | N/A | 835/PLB/CT/04 |
CF011 | Payment Subcategory | N/A | N/A | N/A |
CF012 | Performance Period Year | N/A | N/A | N/A |
CF013 | Performance Period Month | N/A | N/A | N/A |
CF014 | Withhold Amount | N/A | N/A | 835/PLB/E3/04 |
CF015 | Member Gender | 11 | 3 | 837/2010BA/DMG/03, 837/2010CA/DMG/03 |
CF016 | Member Date of Birth | 10 | 3 | 837/2010BA/DMG/D8/02, 837/2010CA/DMG/D8/02 |
CF017 | Rendering Provider Specialty | N/A | N/A | professional: 837/2420A/PRV/PXC/03; 837/2310B/PRV/PXC/03; institutional: 837/2000A/PRV/PXC/03 |
CF018 | Rendering Provider Number | 57 | N/A | 835/2100/REF/1A/02, 835/2100/REF/1B/02, 835/2100/REF/1C/02, 835/2100/REF/1D/02, 835/2100/REF/G2/02, 835/2100/NM1/BD/09, 835/2100/NM1/BS/09, 835/2100/NM1/MC/09, 835/2100/NM1/PC/09 |
CF019 | Rendering Provider Tax ID | 5 | 25 (only if EIN) | 835/2100/NM1/FI/09 |
CF020 | National Provider ID - Rendering Provider | 56 | 24J | 835/PLB/01; professional: 837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09; institutional: 837/2010AA/NM1/XX/09 |
CF021 | Rendering Provider Last Name or Organization Name | 1 | 31 | professional: 837/2420A/NM1/82/1/03; 837/2310B/NM1/82/1/03; institutional: 837/2010AA/NM1/85/2/03 |
CF022 | Rendering Provider First Name | N/A | 31 | professional: 837/2420A/NM1/82/04; 837/2310B/NM1/82/04; institutional: N/A |
CF023 | Billing Provider Number | 57 | 33b | 837/2010BB/REF/G2/02 |
CF024 | Billing Provider Tax ID | NA | NA | 837/2010AA/REF/EI/02 |
CF025 | National Provider ID - Billing Provider | 56 | 33a | 837/2010AA/NM1/85/ /XX/09 |
CF026 | Billing Provider Last Name or Organization Name | 1 | 33 | 837/2010AA/NM1/85/ /03 |
CF027 | Member First Name | 8b | 2 | 837/2010CA/NM1/ /04, 837/2010BA/NM1/ /04 |
CF028 | Member Middle Name | 8b | 2 | 837/2010CA/NM1/ /05, 837/2010BA/NM1/ /05 |
CF029 | Member Last Name | 8b | 2 | 837/2010CA/NM1/ /03, 837/2010BA/NM1/ /03 |
CF030 | Member Address Line 1 | 9a | 5 | 837/2010BA/N3/01, 837/2010CA/N3/01 |
CF031 | Member Address Line 2 | 9a | 5 | 837/2010BA/N3/02, 837/2010CA/N3/02 |
CF032 | Member City Name | 9b | 5 | 837/2010BA/N4/01, 837/2010CA/N4/01 |
CF033 | Member State or Province | 9c | 5 | 837/2010BA/N4/02, 837/2010CA/N4/02 |
CF034 | Member ZIP Code | 9d | 5 | 837/2010BA/N4/03, 837/2010CA/N4/03 |
CF035 | Substance Use Disorder (SUD) Indicator | N/A | N/A | N/A |
CF899 | Record Type | N/A | N/A | N/A |
C.M.R. 90, 590, ch. 243, app 590-243-G-2