Sample Claim Form Instructions


A Sample HCFA 1500 Claim Form is required to ensure accurate loading of Provider. Please first determine the following to prevent any processing and/or payment delays:

1. The following sections of the sample claim form must be completed (all other areas are optional, and no PHI should be provided):

    a. Box 24j = This is where the NPI # must be entered, based on what has been determined under item 1 above.

    b. Box 25 = Federal Tax Identification #

    c. Box 31 = Rendering Provider’s Name (degree is optional; name should be legal name)

    d. Box 32 = Service Location of where services were rendered. In most cases, this address should match the address that is being given as that will be the Provider’s Primary Address, or Alternate Location.

    e. Box 33 = The Provider’s Pay To Address.

    NOTE: A copy of your Professional 837p is an acceptable alternative to a HCFA 1500:

      i. Bill to Loop 2010AA- Provider qualifier ‘85’

      ii. Rendering Loop 2310B-Provider qualifier ‘82’

      iii. Service Facility Loop 2310D or Loop 2420C- qualifier ‘77’ or ‘FA’

      IMPORTANT: Information in Box 33 of Sample Claim MUST match the pay-to information that is being billed electronically. Please double check this field to ensure that the PAY-TO information is reflected and not the BILL-TO.


A Sample UB04 Claim Form is required for Institutional Providers (i.e. Hospitals, Distinct Part Unit Psychiatric, Distinct Part Unit Rehabilitation, Home Health, etc.).

2. Sample Form UB04 is required for Institutional Providers:

    a. Box 1 = Physical Location

    b. Box 2 = Billing Address (if different)

    c. Box 5 = Vendor TIN

    d. Box 56 = NPI #

    e. Also, Distinct Part Unit Psychiatric, Distinct Part Unit Rehabilitation, and Home Health require a sample claim on a UB04.

    NOTE: A copy of your Institutional 837I is an acceptable alternative to a UB04:

      i. Bill To Loop 2010AA – Provider qualifier ‘85’

      ii. Pay To Loop 2010AB – Provider qualifier ‘87’

      iii. Service Facility 2310E – qualifier ‘FA’