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The following options are on the1500 Claimstab for 1500 paper claims or on theUB Claimstab for UB paper claims.
Use the following table to select the qualifier that you want to populate in the box number or form locator number for the claim type selected in theProcess as Claim Typefield.
| Qualifier | Box Number (1500 Claims) Form Locator Number (UB Claims) |
|---|---|
| Blue Cross Provider Number (1A) | 19, 32b, 33b, FL76, FL77, FL78 |
| Blue Shield Provider Number (1B) | 17a, 19, 24i, 32b, 33b, FL76, FL77, FL78 |
| CHAMPUS Identification Number (1H) | 17a, 19, 24i, 32b, 33b, FL76, FL77, FL78 |
| Clinic Number (FH) | 19, 33b |
| Clinical Lab Improvement Amendment Nbr (X4) | 32b |
| Dental License Number (1E) | 19, FL76, FL77, FL78 |
| Employers Id Number (EI) | 17a, 19, 24i, 32b, 33b, FL76, FL77, FL78 |
| Facility ID Number (1J) | 19, 33b |
| Health Maint Org Code Number (BQ) | 19, 33b |
| Location Number (LU) | 17a, 19, 24i, 32b, 33b, FL76, FL77, FL78 |
| Medicaid Provider Number (1D) | 17a, 19, 24i, 32b, 33b, FL76, FL77, FL78 |
| Medicare Provider Number (1C) | 17a, 19, 24i, 32b, 33b, FL76, FL77, FL78 |
| Network Identification Number (N5) | 17a, 19, 24i, 32b, FL76, FL77, FL78 |
| Preferred Prov Org Number (B3) | 19, 33b |
| Provider Commercial Number (G2) | 17a, 19, 24i, 32b, 33b, FL76, FL77, FL78 |
| Provider Site Number (G5 | 19, 32b, 33b |
| Provider UPIN Number (1G) | 17a, 19, 24i, 32b, 33b, FL76, FL77, FL78 |
| Social Security Number (SY) | 17a, 19, 24i, 33b, FL76, FL77, FL78 |
| State Ind Accident Prov Number (X5) | 17a, 19, 24i, 32b, 33b, FL76, FL77, FL78 |
| State License Number (0B) | 17a, 19, 24i, 32b, 33b, FL76, FL77, FL78 |
| Taxonomy Code (ZZ) | FL81 |
| Taxonomy Code (ZZ) | 17a, 19, 24i, 32b, 33b |
| Taxpayer Identification Number (TJ) | 19, 32b |
| USIN (U3) | 19, 33b |
| Y4 | 11b |