In General. To qualify as a clean claim, a claim submitted to a third-party payor by a health care practitioner as provided in Regulation .03 of this chapter, or by a person entitled to reimbursement, shall conform to the applicable standard code set and include the following data elements: Subscriber's plan ID number (HCFA Form 1500, field 1a); Patient's name (HCFA Form 1500, field 2); Patient's date of birth and gender (HCFA Form 1500, field 3); Subscriber's name (HCFA Form 1500, field 4); Patient's address (street or P.O. box, city, and zip code) (HCFA Form 1500, field 5); Patient's relationship to the subscriber (HCFA Form 1500, field 6); Subscriber's address (street or P.O. box, city, and zip code) (HCFA Form 1500, field 7); Except in the case of a laboratory issued a license pursuant to Health-General Article, §17-205, Annotated Code of Maryland, patient status (HCFA Form 1500, field 8); Whether the patient's condition is related to employment (HCFA Form 1500, field 10(a)); Whether the patient's condition is related to an auto accident (HCFA Form 1500, field 10(b)); Whether the patient's condition is related to an accident other than an auto accident (HCFA Form 1500, field 10(c)); Subscriber's policy number (HCFA Form 1500, field 11); Except in the case of a laboratory issued a license pursuant to Health-General Article, §17-205, Annotated Code of Maryland, subscriber's birth date and gender (HCFA Form 1500, field 11a); Except in the case of a laboratory issued a license pursuant to Health-General Article, §17-205, Annotated Code of Maryland, name of the third-party payor (HCFA Form 1500, field 11c); Disclosure of any other health benefit plans (HCFA Form 1500, field 11d); Patient's or authorized person's signature or notation that the signature is on file with the health care practitioner (HCFA Form 1500, field 12); Subscriber's or authorized person's signature or notation that the signature is on file with the health care practitioner or person entitled to reimbursement, if applicable (HCFA Form 1500, field 13); Except in the case of a laboratory issued a license pursuant to Health-General Article, §17-205, Annotated Code of Maryland, date of current illness, injury, or pregnancy (HCFA Form 1500, field 14); Except in the case of a health care practitioner for emergency services, or a laboratory issued a license pursuant to Health-General Article, §17-205, Annotated Code of Maryland, whether the patient has had the same or a similar illness (HCFA Form 1500, field 15); Except in the case of a health care practitioner for emergency services, the name of the referring physician or health maintenance organization (HCFA Form 1500, field 17); Hospitalization dates related to current services, if applicable (HCFA Form 1500, field 18); Diagnosis codes or nature of the illness or injury (HCFA Form 1500, field 21); Date of service (HCFA Form 1500, field 24A); Place of service codes for all claims, as designated by HFCA for Medicare (HCFA Form 1500, field 24B); Procedure code (HCFA Form 1500, field 24D); Diagnosis code by specific service (HCFA Form 1500, field 24E); Charge for each listed service (HCFA Form 1500, field 24F); Number of days, time (minutes), start and stop time, or units (HCFA Form 1500, field 24G); The carrier-assigned rendering provider number until the National Provider Identifier is developed and assigned, if applicable (HCFA Form 1500, field 24K); Health care practitioner's or person entitled to reimbursement's federal tax ID number (HCFA Form 1500, field 25); Patient's account number (HCFA Form 1500, field 26); Total charge (HCFA Form 1500, field 28); For claims: Submitted electronically, a computer-printed name as the signature of the health care practitioner or person entitled to reimbursement (HCFA Form 1500, field 31), or Not submitted electronically, the signature of the health care practitioner who provided the service, or person entitled to reimbursement who provided the service, or notation that the signature is on file with the HMO or preferred provider carrier (HCFA Form 1500, field 31); Name and address of the facility where services were rendered (if other than home or office) (HCFA Form 1500, field 32); Health care practitioner's or person entitled to reimbursement's billing name, address, zip code, phone number, and, if applicable, carrier-assigned provider number until the National Provider Identifier (NPI) is developed and assigned, including a provider number pursuant to Health-General Article, §19-710.1(b)(3), Annotated Code of Maryland, (HCFA Form 1500, field 33); and Any other field or essential data element necessary to comply with the applicable standard code set. Specific Circumstances. In addition to the data elements required by §A of this regulation, to qualify as a clean claim, a claim submitted to a third-party payor by a health care practitioner or person entitled to reimbursement shall include the following data elements if circumstances exist that render the data elements applicable to the specific claim being filed: The other insured's or enrollee's name (HCFA Form 1500, field 9) is applicable if the patient is covered by more than one health benefit plan; The other insured's or enrollee's policy/group number (HCFA Form 1500, field 9a) is applicable if the patient is covered by more than one health benefit plan; The other insured's or enrollee's date of birth (HCFA Form 1500, field 9b) is applicable if the patient is covered by more than one health benefit plan; The other insured's or enrollee's plan name (employer, school, etc.) (HCFA Form 1500, field 9c) is applicable if the patient is covered by more than one health benefit plan; The other insured's or enrollee's HMO or insurer name (HCFA Form 1500, field 9d) is applicable if the patient is covered by more than one health benefit plan; Except in the case of a laboratory issued a license pursuant to Health-General Article, §17-205, Annotated Code of Maryland, the subscriber's plan name (employer, school, etc.) (HCFA Form 1500, field 11(b)) is applicable if the health benefit plan is a group plan; The prior authorization number (HCFA Form 1500, field 23) is applicable when prior authorization is required; A code pursuant to a global contract (HCFA Form 1500, field 24D) is applicable if the claim is between parties to a global contract; A code established by the Medicaid Program (HCFA Form 1500, field 24D) is applicable if the claim is for services rendered pursuant to Health-General Article, §15-103(b)(2), Annotated Code of Maryland; The modifier code (HCFA Form 1500, field 24(D)) is applicable when a modifier code is used to explain unusual circumstances; Whether an assignment was accepted (HCFA Form 1500, field 27) is applicable when an assignment has been accepted; The amount paid (HCFA Form 1500, field 29) is applicable if an amount has been paid to the health care practitioner or person entitled to reimbursement submitting the claim, by the patient or subscriber, or on behalf of the patient or subscriber; and The balance due (HCFA Form 1500, field 30) is applicable if an amount has been paid to the health care practitioner or person entitled to reimbursement submitting the claim, by the patient or subscriber, or on behalf of the patient or subscriber. A third-party payor may not use or require a health care practitioner or person entitled to reimbursement to use any field for purposes that are inconsistent with these essential data elements or in addition to the applicable standard code set. A third-party payor may accept a HCFA Form 1500 that includes data elements in addition to those set forth in §§A and B of this regulation.