REFERENCE / CLAIM FORMS
Claim forms, annotated
Field-by-field annotated references for the three claim formats every claims analysis is built on. Each field links to the repository concept that explains what it means for your study.
annotated CMS-1500 / 837P form
PROFESSIONAL CLAIMS
CMS-1500 / 837P
Physician services: CPT codes, place of service, rendering vs billing provider.
annotated UB-04 / 837I form
INSTITUTIONAL CLAIMS
UB-04 / 837I
Inpatient and facility claims: revenue codes, DRGs, admitting diagnosis.
annotated NCPDP form
PHARMACY CLAIMS
NCPDP
Dispensing records: NDC, days supply, quantity, DAW, reversals.
Companion track: Claims Data Foundations → 12 steps
The annotated UB-04
Three annotated facsimiles of the CMS-1450 (UB-04) institutional claim — Inpatient, Outpatient, and Emergency Department — populated with synthetic data. The Emergency Department variant pairs the facility claim with its companion CMS-1500 professional claim. Click any numbered marker to see what the field means and why RWE analysts care about it.
Educational facsimile only. All patient, provider, and financial data are
entirely synthetic. UB-04 (CMS-1450) is maintained by NUBC (© American Hospital Association).
Field definitions per public CMS Claims Processing Manual Ch. 25. Not for billing use.
Claim field list
Form field (rule color echoes the CMS red dropout ink)
Numbered marker → click for RWE annotation
Variant: Inpatient · Heart failure admission · DRG 292 · 4-day stay
1–5
Provider name / address / phone
STONEBRIDGE GENERAL HOSPITAL
475 MILLBROOK PKWY
STONEBRIDGE, MA 01452
TEL: 508-555-0100
3a
Patient control no
PT-2024-088431
3b
Medical record no
MRN-441892
4
Type of bill
0111
5
Fed tax no
04-3891220
6
Statement covers period FROM
2024-03-10
6
THROUGH
2024-03-14
7
(Reserved)
8a
Patient ID
HIC-881234567A
8b
Patient name (Last, First MI)
DOE, JANE Q
9a
Patient address
22 OAK RIDGE RD
9b
City
STONEBRIDGE
9c
State
MA
9d
ZIP
01452
10
DOB
1952-08-17
11
Sex
F
12
Admission date
2024-03-10
13
Admit hr
14
14
Type of admit
2
15
Pt source
7
16
Disch hr
11
17
Pat status
01
18–28
Condition codes
31
Occur code/date
11 2024-03-10
32
Occur code/date
33
Occur code/date
34
Occur code/date
35
Occur span code/dates
36
Occur span code/dates
37
Internal control no
ICN-2024-88431
39
Value code / amount
A1 / $4.00
40
Value code / amount
41
Value code / amount
38
Responsible party name / address
DOE, JANE Q 22 OAK RIDGE RD STONEBRIDGE MA 01452
| FL42 Rev Cd | FL43 Description | FL44 HCPCS/Rate | FL45 Serv Date | FL46 Units | FL47 Total Charges | FL48 Non-Cvrd Chgs |
|---|---|---|---|---|---|---|
| 0120 | MED/SURG ROOM&BOARD | (no HCPCS) | 2024-03-10 | 4 | $6,100.00 | |
| 0250 | PHARMACY | 2024-03-10 | 1 | $892.50 | ||
| 0260 | IV THERAPY | 2024-03-10 | 2 | $630.00 | ||
| 0301 | LAB/HEMATOLOGY | 2024-03-10 | 1 | $284.00 | ||
| 0730 | EKG/ECG | 2024-03-10 | 1 | $210.00 | ||
| 0001 | TOTALS | $8,116.50 | $0.00 |
50
Payer name (A=primary)
A: MEDICARE TRADITIONAL
51
Health plan ID
A: 00112
52
Rel info
Y
53
Asgn ben
Y
54
Prior payments
$0.00
55
Est amount due
$8,116.50
56
NPI (billing provider)
1004567818
57
Other provider ID
58
Insured's name
DOE, JANE Q
59
P rel
18
60
Cert/SSN/HI#/ID
1HH4-A72-9981
61
Group name
MEDICARE PART A
62
Group no
PARTA
63
Treatment auth codes
64
Doc ctrl no
DCN-8843100
65
Employer name
RETIRED
FL66–FL67 Principal/Secondary Diagnoses (ICD-10-CM) & POA Indicators
FL66 DX Version Qual
0 (ICD-10)
FL67 Principal Dx
I50.23
POA: Y
A Other Dx
I10
POA: Y
B Other Dx
E11.9
POA: Y
C Other Dx
N17.9
POA: N
D Other Dx
E Other Dx
69
Admitting diagnosis
R06.02
70
Patient's reason for visit
(inpatient: not required)
71
PPS code/DRG
292
72
External cause of injury
FL74 Principal procedure
(blank)
74a Other procedure
74b Other procedure
74c Other procedure
74d Other procedure
76
Attending NPI / Name
5009876454
CHEN, MICHAEL R MD
77
Operating NPI / Name
78
Other provider NPI / Name
79
Other provider NPI / Name
80
Remarks
81a
CC qualifier
B3
81b
Code
02
81cc
Value
MEDICARE REMIT CODE
You can’t curate claims data you can’t read. The repository has
the field-by-field deep dives; Claims Data Foundations puts them in order.