This blog post describes the mapping specifications and the conversion between HIPAA 837 institutional and CMS 1450 (also known as UB04) in PDF format.
We have been in the HIPAA compliance and conversion business for the past 18 years. Through the years, we have developed more than 300 pre-defined HIPAA maps that allow users to plug and play the maps into the users’ system with no further work. One of the pre-defined maps that we have done a while ago is the HIPAA 837 Institutional (5010_A2) to CMS 1450 form in PDF format.
You can test the map by going to Redix HIPAA Compliance and Conversion Demo.
A blank CMS 1450 or UB04 form looks like the following. 
Mapping Specification
The CMS 1450 form is using the box id to identify the meaning of each field. For example, a patient name is in box 8a and the patient address is in 9a. The patient name in a HIPAA 837 institutional is defined in 2010BA. Below is a table to describe the box id in the CMS 1450 form and its corresponding element in HIPAA 837 Institutional.
| CMS 1450 Form Box ID | HIPAA 837 Institutional Corresponding Field(s) |
|---|---|
| 1 | 2010AA NM103, N3xx, N4xx, PER04,06,08 (when qualifier is "TE") |
| 2 | NM103, N3xx, N4xx, NM108, NM109 from 2010AA. Overwritten by 2010AB when exists. |
| 3a | 2300 CLM01 (not always PCN) |
| 3b | 2300 REF02 (REF01="EA") |
| 4 | 2300 CLM05:01 + :03 |
| 5 | 2010AA NM109 (NM108="24") | REF01 (REF02="EI") |
| 6 | 2300 DTP03 (DTP01="434"), converted |
| 7 | (Internally Used) |
| 8a | 2010BA | overwritten by 2010CA NM109 | REF01-02 |
| 8b | 2010BA | overwritten by 2010CA NM103-05 |
| 9a | 2010BA | overwritten by 2010CA N3xx |
| 9b | 2010BA | overwritten by 2010CA N401 |
| 9c | 2010BA | overwritten by 2010CA N402 |
| 9d | 2010BA | overwritten by 2010CA N403 |
| 9e | 2010BA | overwritten by 2010CA N404 |
| 10 | 2010BA | overwritten by 2010CA DMG02, converted |
| 11 | 2010BA | overwritten by 2010CA DMG03 |
| 12 | 2300 DTP03 (DTP01="435"), split, converted |
| 13 | 2300 DTP03 (DTP01="435"), split, converted |
| 14 | 2300 CL101 |
| 15 | 2300 CL102 |
| 16 | 2300 DTP03 (DTP01="096"), converted |
| 17 | 2300 CL103 |
| 18 | 2300 HI01:02 (HI01:01="BG") |
| 19 | 2300 HI02:02 (HI01:01="BG") |
| 20 | 2300 HI03:02 (HI01:01="BG") |
| 21 | 2300 HI04:02 (HI01:01="BG") |
| 22 | 2300 HI05:02 (HI01:01="BG") |
| 23 | 2300 HI06:02 (HI01:01="BG") |
| 24 | 2300 HI07:02 (HI01:01="BG") |
| 25 | 2300 HI08:02 (HI01:01="BG") |
| 26 | 2300 HI09:02 (HI01:01="BG") |
| 27 | 2300 HI10:02 (HI01:01="BG") |
| 28 | 2300 HI11:02 (HI01:01="BG") |
| 29 | 2300 CLM11:04 |
| 30 | (Internally Used) |
| 31 | 2300 HI01:02, :04, converted (HI01:01="BH") |
| 32 | 2300 HI02:02, :04, converted (HI01:01="BH") |
| 33 | 2300 HI03:02, :04, converted (HI01:01="BH") |
| 34 | 2300 HI04:02, :04, converted (HI01:01="BH") |
| 35 | 2300 HI02:02, :04, converted (HI01:01="BI") |
| 36 | 2300 HI02:02, :04, converted (HI01:01="BI") |
| 37 | (Internally Used) |
| 38 | 2010BA NM103, NM104, N3xx, N4xx |
| 39a | 2300 HI01:02, :05 (HI01:01="BE") |
| 39b | 2300 HI04:02, :05 (HI01:01="BE") |
| 39c | 2300 HI07:02, :05 (HI01:01="BE") |
| 39d | 2300 HI10:02, :05 (HI01:01="BE") |
| 40a | 2300 HI02:02, :05 (HI01:01="BE") |
| 40b | 2300 HI05:02, :05 (HI01:01="BE") |
| 40c | 2300 HI08:02, :05 (HI01:01="BE") |
| 40d | 2300 HI11:02, :05 (HI01:01="BE") |
| 41a | 2300 HI03:02, :05 (HI01:01="BE") |
| 41b | 2300 HI06:02, :05 (HI01:01="BE") |
| 41c | 2300 HI09:02, :05 (HI01:01="BE") |
| 41d | 2300 HI12:02, :05 (HI01:01="BE") |
| 42 (1-22) | 2400 SV201 |
| 43 (1-22) | 2400 SV202:02, xwalked from codef database |
| 44 (1-22) | 2400 SV202:02,:03,:04,:05,:06 all concatenated |
| 45 (1-22) | 2400 DTP03, converted (DTP01="R72") |
| 46 (1-22) | 2400 SV205 |
| 47 (1-22) | 2400 SV203 |
| 48 (1-22) | 2400 SV207 |
| 49 (1-22) | (internally used) |
| 50a | All boxes 50-65 placed using qualifier SBR01 2010BB | 2330B NM103 (Payor roll is primary) |
| 50b | 2010BB | 2330B NM103 (Payor roll is secondary) |
| 50c | 2010BB | 2330B NM103 (Payor roll is tertiary) |
| 51a | 2010BB | 2330B NM109 (Payor roll is primary) |
| 51b | 2010BB | 2330B NM109 (Payor roll is secondary) |
| 51c | 2010BB | 2330B NM109 (Payor roll is tertiary) |
| 52a | 2300 CLM09 | 2330 OI06 (Payor roll is primary) |
| 52b | 2300 CLM09 | 2330 OI06 (Payor roll is secondary) |
| 52c | 2300 CLM09 | 2330 OI06 (Payor roll is tertiary) |
| 53a | 2300 CLM08 | 2330 OI03 (Payor roll is primary) |
| 53b | 2300 CLM08 | 2330 OI03 (Payor roll is secondary) |
| 53c | 2300 CLM08 | 2330 OI03 (Payor roll is tertiary) |
| 54a | 2300 AMT02 (AMT01="F5") | 2330 AMT02 (AMT01="D") (Payor roll is primary) |
| 54b | 2300 AMT02 (AMT01="F5") | 2330 AMT02 (AMT01="D") (Payor roll is secondary) |
| 54c | 2300 AMT02 (AMT01="F5") | 2330 AMT02 (AMT01="D") (Payor roll is tertiary) |
| 55a | DNE |
| 55b | DNE |
| 55c | DNE |
| 56 | 2010BA | 2330A NM109 (NM109="XX") |
| 57a | 2010BA | 2330A REF02 contatenating all (Payor roll is primary) |
| 57b | 2010BA | 2330A REF02 contatenating all (Payor roll is secondary) |
| 57b | 2010BA | 2330A REF02 contatenating all (Payor roll is tertiary) |
| 58a | 2010BA | 2330A NM103-05 (Payor roll is primary) |
| 58b | 2010BA | 2330A NM103-05 (Payor roll is secondary) |
| 58c | 2010BA | 2330A NM103-05 (Payor roll is tertiary) |
| 59a | 2000B | 2320 SBR02 (crosswalked) (Payor roll is primary) |
| 59b | 2000B | 2320 SBR02 (crosswalked) (Payor roll is secondary) |
| 59c | 2000B | 2320 SBR02 (crosswalked) (Payor roll is tertiary) |
| 60a | 2010BA | 2330A NM109 (Payor roll is primary) |
| 60b | 2010BA | 2330A NM109 (Payor roll is secondary) |
| 60c | 2010BA | 2330A NM109 (Payor roll is teritary) |
| 61a | 2000B | 2320 SBR04 (Payor roll is primary) |
| 61b | 2000B | 2320 SBR04 (Payor roll is secondary) |
| 61c | 2000B | 2320 SBR04 (Payor roll is tertiary) |
| 62a | 2000B | 2320 SBR03 (Payor roll is primary) |
| 62b | 2000B | 2320 SBR03 (Payor roll is secondary) |
| 62c | 2000B | 2320 SBR03 (Payor roll is tertiary) |
| 63a | 2300 | 2330B REF02 (REF01="G1") (Payor roll is primary) |
| 63b | 2300 | 2330B REF02 (REF01="G1") (Payor roll is secondary) |
| 63c | 2300 | 2330B REF02 (REF01="G1") (Payor roll is tertiary) |
| 64a | 2300 | 2330B REF02 (REF01="F8") (Payor roll is primary) |
| 64b | 2300 | 2330B REF02 (REF01="F8") (Payor roll is secondary) |
| 64c | 2300 | 2330B REF02 (REF01="F8") (Payor roll is tertiary) |
| 65a | Employer DNE in 837 |
| 65b | Employer DNE in 837 |
| 65c | Employer DNE in 837 |
| 66 | "9" or "0" based on ICD qualifier |
| 67 | 2300 HI01:02 (HI01:01="BK" | "ABK") |
| 67a | 2300 HI01:02 (HI01:01="BF" | "ABF") |
| 67b | 2300 HI02:02 (HI02:01="BF" | "ABF") |
| 67c | 2300 HI03:02 (HI03:01="BF" | "ABF") |
| 67d | 2300 HI04:02 (HI04:01="BF" | "ABF") |
| 67e | 2300 HI05:02 (HI05:01="BF" | "ABF") |
| 67f | 2300 HI06:02 (HI06:01="BF" | "ABF") |
| 67g | 2300 HI07:02 (HI07:01="BF" | "ABF") |
| 67h | 2300 HI08:02 (HI08:01="BF" | "ABF") |
| 67i | 2300 HI09:02 (HI09:01="BF" | "ABF") |
| 67j | 2300 HI10:02 (HI10:01="BF" | "ABF") |
| 67k | 2300 HI11:02 (HI11:01="BF" | "ABF") |
| 67l | 2300 HI12:02 (HI12:01="BF" | "ABF") |
| 67m | 2300 HI01:02 (second HI) (HI01:01="BF" | "ABF") |
| 67n | 2300 HI02:02 (second HI) (HI02:01="BF" | "ABF") |
| 67o | 2300 HI03:02 (second HI) (HI03:01="BF" | "ABF") |
| 67p | 2300 HI04:02 (second HI) (HI04:01="BF" | "ABF") |
| 67q | 2300 HI05:02 (second HI) (HI05:01="BF" | "ABF") |
| 68 | (internally used) |
| 69 | 2300 HI02:02 (HI02:01="BJ" | "ABJ") |
| 70a | 2300 HI01:01 (HI01:01="PR" | "APR") |
| 70b | 2300 HI02:01 (HI02:01="PR" | "APR") |
| 70c | 2300 HI03:01 (HI03:01="PR" | "APR") |
| 71 | DNE |
| 72a | 2300 HI01:02 (HI01:01="BK" | "ABK") |
| 73 | (internally used) |
| 74 | 2300 HI01:02,:04, converted (HI01:01="BP"| "BR"| "ABR") |
| 74a | 2300 HI01:02,:04, converted (HI qual="BO" | "BQ" | "BBQ") |
| 74b | 2300 HI02:02,:04, converted (HI qual="BO" | "BQ" | "BBQ") |
| 74c | 2300 HI03:02,:04, converted (HI qual="BO" | "BQ" | "BBQ") |
| 74d | 2300 HI04:02,:04, converted (HI qual="BO" | "BQ" | "BBQ") |
| 74e | 2300 HI05:02,:04, converted (HI qual="BO" | "BQ" | "BBQ") |
| 75 | (internally used) |
| 76 | 2310A NM109,08,03,04 |
| 77 | 2310B NM109,08,03,04 |
| 78 | 2310C NM109,08,03,04 |
| 79 | DNE |
| 80 | 2300 NTE02 |
| 81 | (reserved for proprietary usage) |
| Other Locations on Form | |
| Creation Date | System Date |
| Page | Total Service Lines / 22, rounded up |
| Of (page) | Current LX count mod 22 calculation |
| Total Covered Charges | SUM 2400 SV203 |
| Total Non-Covered Charges | SUM 2400 SV207 |
| Other Notes | |
| "Payor Roll" | A notion (via variable in the OFD) that defined if entity is in reference to Primary, Secondary or Tertiary payment roll. Used to determine if block of data is in reference to "submitting" insurance, or "other insurance". |
| End of Crosswalk |
Notes
We have developed a conversion tool that will take an 837 institutional file and convert it to the UB04 form in PDF format. Some of the notes about this conversion:
- The input file will be validated first. Only the file 837 is validated successfully; the 837 file will be converted.
- Each claim will result in a separate CMS 1450 PDF file.
Example
Below is an 837 Institutional example:
ISA*00* *01*SECRET *ZZ*SUBMITTERS ID *ZZ*RECEIVERS ID *030101*1253*^*00501*000000905*1*T*: GS*HC*SENDER CODE*RECEIVER CODE*19991231*0802*1*X*005010X223A2 ST*837*1024*005010X223A2 BHT*0019*00*1024*20050711*1335*CH NM1*41*2*REGIONAL PPO NETWORK*****46*123456789 PER*IC*SUBMITTER CONTACT INFO*TE*8001231234 NM1*40*2*CONSERVATIVE INSURANCE*****46*000110002 HL*1**20*1 NM1*85*2*LOCAL HOSPITAL*****XX*1122334455 N3*3423 SMALL STREET N4*COLUMBUS*OH*432150000 REF*EI*111002222 HL*2*1*22*0 SBR*P*18*34561W******CI NM1*IL*1*SMITH*JAMES*A***MI*34902390F N3*934 NORTH STREET N4*COLUMBUS*OH*432150000 DMG*D8*19621015*M NM1*PR*2*CONSERVATIVE INSURANCE*****PI*00123 CLM*W392-49141*14.84***13:A:1**A*Y*Y DTP*434*RD8*20050617-20050617 DTP*435*DT*200506170800 CL1*1*1*01 AMT*F3*14.84 REF*9A*459804390823 REF*D9*32423466233 HI*BK:53081 HCP*00*0**333001234*********T1 NM1*71*1*RIVERS*DAWN****XX*1234567893 REF*1G*A12345 LX*1 SV2*0301*HC:A9999*14.84*UN*1 DTP*472*D8*20050617 SE*32*1024 GE*1*1 IEA*1*000000905
The generated PDF file is as follows.
About Us
Redix International, Inc. is an enterprise software company. Redix develops software and provides services to help organizations convert their proprietary or organization-specific data to standardized data. Among the standardized formats supported are X12, EDIFACT, XML, NSF, UB92, HIPAA, HL7, CDA, Blue-Ribbon, FHIR, NCPDP, and PDF.