FL Requirement Description Line Type Size

Transcription

1 UB-04 Claim Form 1

2 UB-04 Data Elements 1 Billing Provider Name Billing Provider Street Address Billing Provider City, State, Zip 3 5 Billing Provider Telephone, Fax, Country Code 4 5 Billing Provider's Designated Pay-to Name 1 5 Billing Provider's Designated Pay-to Address 5 Billing provider's Designated Pay-to City, State 3 5 Billing provider's Designated Pay-to ID 4 5 3a Patient Control Number 1 4 3b Medical/Health Record Number 4 4 Type of Bill (TOB) Federal Tax Number 1 4 Federal Tax Number 10 6 Statement Covers Period - From/Through 1 N/N 6/6 7 Field not used Unlabeled 1 7 Field not used Unlabeled 8 8a Patient Name/ID b Patient Name 9 9a Patient Address - Street b Patient Address - City 30 9c 9d Patient Address - State Patient Address - Zip 9 9e Patient Address - Country Code 3 10 Patient Birthdate 1 N 8 11 Patient Sex Required for Types of Bill 011X, 01X, 018X, 01X, 0X, 03X, 033X, 041X, 081X, or 08X Admission/Start of Care Date 1 N 6

3 13 Admission Hour 1 14 Required for Types of Bill 011X, 01X, 018X, 01X, and 041X Priority (Type) of Admission or Visit Point of Origin for Admission or Visit Discharge Hour 1 17 Required for Types of Bill 011X, 01X, 013X, 014X, 018X, 01X, 0X, 03X, 03X, 033X, 034X, 041X, 071X, 073X, 074X, 075X, 076X, 081X, 08X, 085X Patient Discharge Status Condition Codes 9 Accident State 30 Field not used Unlabeled 1 1 Field not used Unlabeled Occurrence Code/Date a /N /6 Occurrence Code/Date b /N / Occurrence Span Code/From/Through a /N/N /6/6 Occurrence Span Code/From/Through b /N/N /6/6 37 Field not used Unlabeled a 8 Field not used Unlabeled b 8 38 Responsible Party Name/Address 1 40 Responsible Party Name/Address 40 Responsible Party Name/Address 3 40 Responsible Party Name/Address 4 40 Responsible Party Name/Address Value Code a-d Value Code Amount a-d N 9 3

4 4 Revenue Codes 1-3 N 4 43 Revenue Code Description/Investigational Device Exemption (IDE) Number/Medicaid Drug Rebate Healthcare Common Procedure Coding System (HCPCS)/Accommodation Rates/Health Insurance Prospective Payment System (HIPPS) Rate Codes Service Dates 1-3 N 6 46 Service Units 1-3 N 7 47 Total Charges 1-3 N 9 48 Non-Covered Charges 1-3 N 9 49 Field not used Unlabeled 1-3 Page _ of Creation Date _ 3 N/N 3/3 50 Payer Identification - Primary A 3 Payer Identification - Secondary B 3 Payer Identification - Tertiary C 3 51 Health Plan ID A 15 Health Plan ID B 15 Health Plan ID C 15 5 Release of Information A 1 Release of Information - Secondary B 1 Release of Information - Tertiary C 1 53 Assignment of Benefits - Primary A 1 Assignment of Benefits - Secondary B 1 Assignment of Benefits - Tertiary C 1 54 Prior Payments - Primary A N 10 Prior Payments - Secondary B N 10 Prior Payments - Tertiary C N Estimated Amount Due - Primary A N 10 4

5 Estimated Amount Due - Secondary B N 10 Estimated Amount Due - Tertiary C N National Provider Identifier (NPI) - Billing Provider Other Provider ID A 15 Other Provider ID B 15 Other Provider ID C Insured's Name - Primary A 5 insured's Name - Secondary insured's Name - Tertiary B C Patient's Relationship - Primary A Patient's Relationship - Secondary B Patient's Relationship - Tertiary C 60 Insured's Unique ID - Primary A 0 Insured's Unique ID - Secondary B 0 Insured's Unique ID - Tertiary C 0 61 Insurance Group Name - Primary A 14 Insurance Group Name - Secondary Insurance Group Name - Tertiary B C Insurance Group No. - Primary A 17 Insurance Group No. - Secondary B 17 Insurance Group No. - Tertiary C Treatment Authorization - Primary A 30 Treatment Authorization - Secondary B 30 Treatment Authorization - Tertiary C Document Control Number (DCN) A 6 Document Control Number (DCN) Document Control Number (DCN) B C Employer Name (of the insured) - Primary A 5 Employer Name (of the insured) - Secondary B 5 Employer Name (of the insured) - Tertiary C 5 5

6 66 Diagnosis and Procedure Code Qualifier (International Classification of Diseases [ICD] Version Indicator) Required for Types of Bill 011X. 01X, 013X, 014X, and 01X Principal Diagnosis Code and Present on Admission (POA) Indicator A-Q Other Diagnosis and POA Indicator A-O 8 68 Field not used Unlabeled 1 8 Field not used Unlabeled 9 69 Required for Types of Bill 011X, 01X, 01X, and 0X Admitting Diagnosis Code a Patient Reason for Visit Code b 70c Patient Reason for Visit Code Patient Reason for Visit Code Prospective Payment System (PPS) Code 1 3 7a 7b 7c External Cause of Injury Code and POA Indicator 1 8 External Cause of Injury Code and POA Indicator 1 8 External Cause of Injury Code and POA Indicator Field not used Unlabeled Principal Procedure Code/Date 1 N/N 7/6 74a Other Procedure Code/Date 1 N/N 7/6 74b Other Procedure Code/Date 1 N/N 7/6 74c Other Procedure Code/Date N/N 7/6 74d Other Procedure Code/Date N/N 7/6 74e Other Procedure Code/Date N/N 7/6 75 Field not used Unlabeled 1 3 Field not used Unlabeled 4 Field not used Unlabeled 3 4 Field not used Unlabeled Attending Provider - NPI/QUAL/ID 1 11//9 6

7 Attending Provider - Last/First 16/1 77 Operating Physician - NPI/QUAL/ID 1 11//9 Operating Physician - Last/First 16/1 7

8 78 Other Provider - QUAL/NPI/QUAL/ID 1 /11//9 Other Provider - Last/First 16/1 79 Other Provider - QUAL/NPI/QUAL/ID 1 /11//9 Other Provider - Last/First 16/1 80 Remarks 1 1 Remarks Remarks Remarks Code-Code - QUAL/CODE/VALUE a // /10/1 Code-Code - QUAL/CODE/VALUE b // /10/1 Code-Code - QUAL/CODE/VALUE Code-Code - QUAL/CODE/VALUE c d // // /10/1 /10/1 8