DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION

Transcription

1 DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION FORM (UB-04). 1 PROVIDER NAME, ADDRESS AND TELEPHONE NUMBER Enter the provider's name and a valid telephone number and the physical address (including zip code) of the place where services were rendered. 2 PAY-TO NAME AND ADDRESS Enter the name and address where the provider listed in form locator 1 expects payment to be remitted. 3a PATIENT CONTROL NUMBER T 3b MEDICAL/HEALTH RECORD NUMBER T 4 TYPE OF BILL Pursuant to the UB-04 Manual. Only bill type 083x is accepted for ASCs. YES Revised 01/01/2015 Page 1 of 12

2 FORM (UB-04). 5 FEDERAL TAX NUMBER Enter the Federal Tax Identification Number of the ASC where the service is provided. Also known as the Tax ID number (TIN). YES 6 STATEMENT COVERS PERIOD Enter dates of service in MM/DD/YYYY format. 7 RESERVED (FOR T 8a PATIENT NAME/IDENTIFIER Enter the patient s name Last Name, First Name and Middle initial 8b PATIENT NAME/IDENTIFIER Enter the patient s Social Security Number or Division Assigned Number YES 9a-e PATIENT ADDRESS Enter the patient s mailing address including street address, apartment number or other identifiers, city, state and zip code. 10 PATIENT BIRTHDATE Enter the patient s date of birth in MM/DD/YYYY format. Revised 01/01/2015 Page 2 of 12

3 FORM (UB-04). 11 PATIENT SEX Enter sex of the patient: M for Male F for Female U for Unknown 12 ADMISSION DATE T 13 ADMISSION HOUR T 14 ADMISSION TYPE T 15 ADMISSION SOURCE T 16 DISCHARGE HOUR T 17 PATIENT DISCHARGE STATUS T Revised 01/01/2015 Page 3 of 12

4 FORM (UB-04). 18 CONDITION CODES Enter code 02 in Form Locator CONDITION CODES CONDITIONAL Use of other applicable codes from the UB-04 Manual is optional (if other codes are listed, list them in alphanumeric order in Form locators 19 through 28). 29 ACCIDENT STATE T 30 RESERVED (FOR T 31 OCCURRENCE CODES AND DATES Enter code 04 and enter the date of the accident/illness/injury as MM/DD/YYYY OCCURRENCE CODES AND DATES T OCCURRENCE SPAN CODES AND DATES T Revised 01/01/2015 Page 4 of 12

5 FORM (UB-04). 37 RESERVED (FOR T 38 RESPONSIBLE PARTY NAME AND ADDRESS Enter the name and mailing address of the workers compensation insurer identified in form locator 50. Must enter name, address and zip code VALUE CODES AND AMOUNTS T 42 REVENUE CODE Enter a four digit Revenue Code beside each service described in column 43. The first digit is a leading zero. See NUBC Manual for specific codes. After the last Revenue Code, enter 0001 corresponding with the Total Charges amount in Column 47. YES 43 REVENUE DESCRIPTION Enter a brief description that corresponds to the Revenue Code in column HCPCS/ RATES/HIPPS RATE CODES Pursuant to the UB-04 Manual. CPT, HCPCS, or workers compensation unique code(s) and modifier(s) required for all applicable REV codes on ASC bills. Revised 01/01/2015 Page 5 of 12

6 FORM (UB-04). 45 SERVICE DATE Service Date: Enter the date services are provided. (Applies to Lines 1-22 only.) Use MM/DD/YYYY format. Creation Date: Enter the date in MM/DD/YYYY format that the bill is created on Line 23. This date shall be reported on all pages of the bill. YES 46 SERVICE UNITS Pursuant to the UB-04 Manual. 47 TOTAL CHARGES Enter total charges related to the revenue code for the current billing period noted in Field Number N-COVERED CHARGES T 49 RESERVED (FOR T 50 PAYER NAME T 51 HEALTH PLAN IDENTIFICATION NUMBER T Revised 01/01/2015 Page 6 of 12

7 FORM (UB-04). 52 RELEASE OF INFORMATION CERTIFICATION INDICATOR T 53 ASSIGNMENT OF BENEFITS CERTIFICATION NUMBER T 54 PRIOR PAYMENTS- PAYER T 55 ESTIMATED AMOUNT DUE- PAYER T 56 NATIONAL PROVIDER IDENTIFIER (NPI) Enter the NPI Number of the ASC where services were provided. 57 OTHER PROVIDER IDENTIFIER Enter the alpha characters ASC followed by the facility license number issued by the Florida Agency for Health Care Administration, i.e. ASC####. Out-of-State providers enter the WC unique license #ZZ INSURED S NAME T Revised 01/01/2015 Page 7 of 12

8 FORM (UB-04). 59 PATIENT S RELATIONSHIP TO INSURED T 60 INSURED S UNIQUE IDENTIFIER T 61 (INSURED) GROUP NAME T No 62 INSURANCE GROUP NUMBER T 63 TREATMENT AUTHORIZATION CODES Enter authorization code, authorization or individual s name providing prior authorization for services requested. 64 DOCUMENT CONTROL NUMBER (DCN) T 65 EMPLOYER NAME (OF THE INSURED) T Revised 01/01/2015 Page 8 of 12

9 FORM (UB-04). 66 DIAGSIS AND PROCEDURE CODE QUALIFIER (ICD REVISION INDICATOR) Enter the applicable ICD indicator to identify which version of ICD codes are being reported: 9=ICD-9, 0=ICD-10 TE: ICD-9 shall be used prior to the federal implementation date for the use of the ICD-10. ICD-10 can be used on or after the federal implementation date. (ICD-9 AND ICD-10 CODES CANT BE USED TOGETHER.) YES 67 PRINCIPAL DIAGSIS CODE Enter the principal ICD diagnosis code describing the condition, present at the time of admission or after the admission that is responsible for the admission of the patient for care. TE: ICD-9 shall be used prior to the federal implementation date for the use of the ICD-10. ICD-10 can be used on or after the federal implementation date. (ICD-9 AND ICD-10 CODES CANT BE USED TOGETHER.) Revised 01/01/2015 Page 9 of 12

10 FORM (UB-04). 67 A-Q OTHER DIAGSIS CODES CONDITIONAL Pursuant to the UB-04 Manual. Enter the ICD diagnosis code describing the condition that coexists at the time of admission that may affect the patient s current care. TE: ICD-9 shall be used prior to the federal implementation date for the use of the ICD-10. ICD-10 can be used on or after the federal implementation date. (ICD-9 AND ICD-10 CODES CANT BE USED TOGETHER.) 68 RESERVED (FOR T 69 ADMITTING DIAGSIS CODE T 70a-c PATIENT S REASON DX T 71 PROSPECTIVE PAYMENT SYSTEM (PPS) CODE T 72a-c EXTERNAL CAUSE OF INJURY (ECI) CODE T Revised 01/01/2015 Page 10 of 12

11 FORM (UB-04). 73 RESERVED (FOR T 74 PRINCIPAL PROCEDURE CODE AND DATE T 74a-e OTHER PROCEDURE CODES AND DATES T 75 RESERVED ( FOR T N0 76 ATTENDING PROVIDER NAME AND IDENTIFIERS Enter the attending provider s name (Last, First) after the labeled Attending. Enter the provider s Florida Department of Health license number after the block labeled Qualifier. Outof -State providers enter the WC unique license number ZZ OPERATING PHYSICIAN NAME AND IDENTIFIERS Enter the operating provider s name (Last, First) after the labeled Operating. Enter the provider s Florida Department of Health license number after the block labeled Qualifier. Outof- State providers enter the WC unique license number ZZ Revised 01/01/2015 Page 11 of 12

12 FORM (UB-04) OTHER PROVIDER NAMES AND IDENTIFIERS T 80 REMARKS CONDITIONAL When billing for implant services reported under REV Code 278, the certification amount requested for reimbursement must be determined in accordance with the percentages defined in Rule 69L-7.100, F.A.C. Each component of Implants, Disposables and Shipping must be listed separately in Form Locator 80 by using the required modifiers: (IM, DI, SH) with their associated requested amount. Enter in dollar and cent format for each category. 81a-d CODE-CODE T Revised 01/01/2015 Page 12 of 12