|
Field #
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Data Element
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HB 610 required as indicated (unless otherwise agreed to by contract)
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SB 418 Emergency Rules required as indicated
(Cannot be changed by contract)
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SB 418 Final Rules required as indicated (Cannot be changed by contract)
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|
1
|
Provider’s name, address and telephone number
|
R
|
R
|
R
|
|
3
|
Patient control number
|
R
|
R
|
R
|
|
4
|
Type of bill code
|
R
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R - shall include a “7” in the 3rd position if claim is a duplicate
|
R - shall include a “7” in the 3rd position if claim is a corrected claim
|
|
5
|
Provider’s federal tax ID number
|
R
|
R
|
R
|
|
6
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Statement period (beginning and ending date of claim period)
|
R
|
R
|
R
|
|
7
|
Covered days
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R – if Medicare is a primary or secondary payor
|
R – if Medicare is a primary or secondary payor
|
R – if Medicare is a primary or secondary payor
|
|
8
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Noncovered days
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R – if Medicare is a primary or secondary payor
|
R – if Medicare is a primary or secondary payor
|
R – if Medicare is a primary or secondary payor
|
|
9
|
Coinsurance days
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R – if Medicare is a primary or secondary payor
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R – if Medicare is a primary or secondary payor
|
R – if Medicare is a primary or secondary payor
|
|
10
|
Lifetime reserve days
|
R – if Medicare is a primary or secondary payor and patient was an inpatient
|
R – if Medicare is a primary or secondary payor and patient was an inpatient
|
R – if Medicare is a primary or secondary payor and patient was an inpatient
|
|
12
|
Patient’s name
|
R
|
R
|
R
|
|
13
|
Patient’s address
|
R
|
R
|
R
|
|
14
|
Patient’s date of birth
|
R
|
R
|
R
|
|
15
|
Patient’s gender
|
R
|
R
|
R
|
|
16
|
Patient’s marital status
|
R
|
R
|
R
|
|
17
|
Date of admission
|
R
|
R - for inpatient admissions, observation stays, and emergency room care
|
R - for admissions, observation stays, and emergency room care
|
|
18
|
Admission hour
|
R
|
R - for inpatient admissions, observation stays, and emergency room care
|
R - for admissions, observation stays, and emergency room care
|
|
19
|
Type of admission (e.g. emergency, urgent, elective, newborn)
|
R
|
R - for inpatient admissions
|
R - for admissions
|
|
20
|
Source of admission code
|
R
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R – for inpatient admissions
|
R
|
|
21
|
Discharge hour
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R – if patient was an inpatient or admitted for outpatient observation
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R – for inpatient admissions, outpatient surgeries or observation stays
|
R – for admissions, outpatient surgeries or observation stays
|
|
22
|
Patient status-at-discharge code
|
R
|
R - for inpatient admissions, observation stays, and emergency room care
|
R - for admissions, observation stays, and emergency room care
|
|
24-30
|
Condition codes
|
R – if the CMS UB-92 manual contains a condition code appropriate to patient’s condition
|
R – if the CMS UB-92 manual contains a condition code appropriate to patient’s condition
|
R – if the CMS UB-92 manual contains a condition code appropriate to patient’s condition
|
|
32-35
|
Occurrence codes and dates
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R – if the CMS UB-92 manual contains an occur-rence code appropriate to patient’s condition
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R – if the CMS UB-92 manual contains an occur-rence code appropriate to patient’s condition
|
R – if the CMS UB-92 manual contains an occur-rence code appropriate to patient’s condition
|
|
36
|
Occurrence span code, from and through dates
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R – if the CMS UB-92 manual contains an occur-rence span code appro-priate to patient’s condition
|
R – if the CMS UB-92 manual contains an occur-rence span code appro-priate to patient’s condition
|
R – if the CMS UB-92 manual contains an occur-rence span code appro-priate to patient’s condition
|
|
39-41
|
Value code and amounts
|
R
|
R – for inpatient admissions. If no value codes are applicable to admission, provider can enter value code 01
|
R – for inpatient admissions. If no value codes are applicable to admission, provider can enter value code 01
|
|
42
|
Revenue code
|
R
|
R
|
R
|
|
43
|
Revenue description
|
R
|
R
|
R
|
|
44
|
HCPCS/Rates
|
R – if Medicare is a primary or secondary payor
|
R – if Medicare is a primary or secondary payor
|
R – if Medicare is a primary or secondary payor
|
|
45
|
Service date
|
Not required
|
R – if claim is for outpatient services
|
R – if claim is for outpatient services
|
|
46
|
Units of Service
|
R
|
R
|
R
|
|
47
|
Total Charge
|
R
|
R
|
R
|
|
50
|
HMO or preferred provider carrier name
|
R
|
R
|
R
|
|
51
|
Provider number
|
Not required
|
R - if carrier required provider numbers and gave notice of the requirement to physician/provider prior to 6-17-2003.
|
R - if carrier required provider numbers and gave notice of the requirement to physician/provider prior to 6-17-2003.
|
|
54
|
Prior payments - payor and patient
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R – if payments have been made to provider by or on behalf of patient or scriber or by a primary plan
|
R – if payments have been made to provider by or on behalf of patient or subscriber or by a primary plan
|
R – if payments have been made to provider by or on behalf of patient or subscriber or by a primary plan
|
|
58
|
Subscriber’s name
|
R
|
R – if shown on patient’s ID card
|
R – if shown on patient’s ID card
|
|
59
|
Patient’s relationship to subscriber
|
R
|
R
|
R
|
|
60
|
Patient’s/subscriber’s certificate number, health claim number, ID number
|
R
|
R
|
R – if shown on the patient’s ID card
|
|
62
|
Insurance group number
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Not required
|
R – if a group number is shown on the patient’s ID card
|
R – if a group number is shown on the patient’s ID card
|
|
63
|
Verification codes
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Not required
|
R- if services have been verified per §19.1724 (Verification). Otherwise, treatment authorization codes are required when authorization is required
|
R- if services have been verified per §19.1724 (Verification). Otherwise, treatment authorization codes are required when authorization is required and granted
|
|
67
|
Principal diagnosis code
|
R
|
R
|
R
|
|
68-75
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Diagnoses codes other than principal diagnosis code
|
R – if there are diagnoses other than the principal diagnosis
|
R – if there are diagnoses other than the principal diagnosis
|
R – if there are diagnoses other than the principal diagnosis
|
|
76
|
Admitting diagnosis code
|
Not required
|
R
|
R
|
|
79
|
Procedure coding methods used -
|
R - if the CMS UB-92 manual indicates a procedural coding method appropriate to patient’s condition
|
R - if the CMS UB-92 manual indicates a procedural coding method appropriate to patient’s condition
|
R - if the CMS UB-92 manual indicates a procedural coding method appropriate to patient’s condition
|
|
80
|
Principal procedure code
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R – if patient has undergone an inpatient or outpatient surgical procedure
|
R – if patient has undergone an inpatient or outpatient surgical procedure
|
R – if patient has undergone an inpatient or outpatient surgical procedure
|
|
81
|
Other procedure code
|
R – as an extension of Field 80 if additional surgical procedures were performed
|
R – as an extension of Field 80 if additional surgical procedures were performed
|
R – as an extension of Field 80 if additional surgical procedures were performed
|
|
82
|
Attending physician ID
|
R
|
R
|
R
|
|
85
|
Signature of provider representative or notation that the signature is on file with the HMO or PPO carrier
|
R
|
R – signature of provider representative. Electronic signature, or notation that signature is on file with carrier.
|
R – signature of provider representative. Electronic signature, or notation that signature is on file with carrier.
|
|
86
|
Date bill submitted
|
R
|
R
|
R
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