UB04 Form Locator Elements Standard v3

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Purpose: The purpose of Standard/Specification UB04 Form Locator Elements, is to clearly describe the use of each form locator in the UB04 (CMS1450) claim billing form and its crosswalk to the HIPAA 837 005010X223A2 Institutional implementation guide.  The purpose of standardizing the use of the UB04 is to create a more uniform electronic claim environment.  UHIN Standard UB04 Form Locator Elements, is compatible with all HIPAA requirements.  It creates a uniform billing method for institutional claims.

Applicability:  All institutional claims and encounters.  For Property and Casualty claims please refer to the Property and Casualty / Worker’s Compensation Standard UB04 Form Locator elements.

Basic Concepts: Form Locator use is derived to the greatest degree possible from the Utah Uniform Billing Instruction Manual[1] for the UB04 facility claim form.  A crosswalk from the form locators to the ASC X12 837 005010 Implementation Guide[2] is listed showing loop and segment/element (e.g., 2010AA NM104 means Loop 2010AA, segment NM1, element 04). 

To the greatest degree possible, all generally required information to submit an electronic HIPAA compliant institutional claim is contained in this crosswalk.  However, there will be instances where additional data is required to create a HIPAA-compliant transaction.  Translator vendors must determine how to obtain any additional required data from provider billing or clinical systems.

Detail:

  1. Explanations of the use of each form locator are given in the UB04
  2. Explanations regarding the use of the ASC X12 data elements are given in the ASC X12 837 005010X223A2 implementation guide.
  3. If a Box is marked “Not cross walked” this means that this data element is not carried in the implementation guide.
  4. An ** indicates that this requirement is unique to Utah. None of the Utah requirements contradicts the HIPAA use of the implementation guide.  Utah-specific requirements are kept to a minimum.
  5. All Form Locators required by the implementation guide, are marked REQUIRED. Everything else is used under the conditions described in the implementation guide.  Providers are responsible for knowing when certain Situational data elements are required in the implementation guide.
  6. All data edits on electronic data will conform to the edits outlined in the HIPAA implementation guide.

Use of Paper Form: See the UB04 manual for a detailed review of how each form locator is used. 

Implementation Issues:

  1. This Standard shall be implemented with the implementation of the HIPAA 5010 Institutional implementation guide.
  2. The HIPAA 837 transactions shall be implemented in conjunction with a 999 Functional Acknowledgement and a 277 Claim Acknowledgement transaction.

Payer Implementation Issues

Provider Implementation Issues

  1. Due to Optical Character Recognition system parameters, it is preferred that the UB04 (CMS1450) form that is printed in red be used by the provider

Form Locator Table:

Form Locator 1.            Provider Name, Address and Telephone Number

Form Locator 2.            Pay-To Address

Form Locator 3a.           Patient Control Number (unique claim number)

Form Locator 3b            Medical/Health Record Number

Form Locator 4.            Type of Bill

Form Locator 5.            Federal Tax Number

Form Locator 6.            Statement Covers Period.(MMDDYY)

Form Locator 7.            Reserved

Form Locator 8a.           Patient name.  Last, First and Middle Initial.  Use a comma as the indicator to separate the last, first and middle initial.  No space should be left between a prefix and a name such as MacBeth, VonSchmidt, and McEnroe.   

Form Locator 8b.           Patient Identifier

Form Locator 9a.           Patient Address.

Form Locator 9b.           City 

Form Locator 9c.           State

Form Locator 9d.           Zip

Form Locator 9e.           Country code

Form Locator 10.           Patient Birth Date. (MMDDYYYY)

Form Locator 11.           Patient Sex.

Form Locator 12.           Admission/Start of Care Date (MMDDYY)

Form Locator 13.           Admission Hour

Form Locator 14.           Priority (Type) of Visit

Form Locator 15.           Source of Referral for Admission or Visit

Form Locator 16.           Discharge Hour

Form Locator 17.           Patient Discharge Status

Form Locator 18 - 28.    Condition Codes

Form Locator 29.           Accident State

Form Locator 30.           Reserved 

Form Locator 31- 34.     Occurrence Code and Date.

Form Locator 35-36.      Occurrence Span Code and Dates.

Form Locator 37.           Reserved

Form Locator 38.           Responsible Party Name and Address. 

Form Locator 39-41.      Value Codes and Amounts.

Form Locator 42.           Revenue Codes.  Must be valid UB04 codes

Form Locator 43.           Revenue Description

Form Locator 43.           Page_ of_

Form Locator 44.           HCPCS/Rates/HIPPS Code

Form Locator 45.           Service Date

Form Locator 45.           Creation date

Form Locator 46.           Service Units

Form Locator 47.           Total Charges (This cannot be a negative number.)

Form Locator 48.           Non Covered charges (This cannot be a negative number.)

Form Locator 49.           Reserved

Form Locator 50 a-c.     Payer Name

Form Locator 51a-c.      Health Plan ID Number

Form Locator 52a-c.      Release of Information Certification Indicator

Form Locator 53a-c.      Assignment of Benefits Certification indicator (“Y”, “N” or ”W ”)

Form Locator 54 a-c.     Prior Payments (Other Payer Amounts)

Form Locator 55 a-c.     Estimated Amount Due (Payer)

Form Locator 56.           National Provider Identifier - Billing Provider

Form Locator 57 a-c.     Other (Billing) Provider ID (Secondary Provider Numbers used to identify the provider per payer)

Form Locator 58 a-c.     Insured’s Name 

Form Locator 59 a-c.     Patients Relationship to the Insured

Form Locator 60 a-c.     Insured’s Unique ID

Form Locator 61 a-c.     Insured’s Group Name

Form Locator 62 a-c.     Insured’s Group Number

Form Locator 63 a-c.     Treatment Authorization Code.  This is not a required field.  However, it is recommended that this information is sent if appropriate to the claim.

Form Locator 64 a-c.     Document Control Number.(Payers Original Claim Number)

Form Locator 65a-c.      Employer Name (of the Insured)

Form Locator 66.           Diagnosis and Procedure Code Qualifier (ICD Version Indicatory) 

Form Locator 67.           Principal Diagnosis Code and Present on Admission Indicator. (Required)

Form Locator 67a-q.      Other Diagnosis codes.  V and E codes are appropriate.

Form Locator 68.           Reserved

Form Locator 69.           Admitting Diagnosis

Form Locator 70a-c.      Patient’s reason for visit

Form Locator 71.           Prospective Payment System (PPS) Code (Used by Medicare)   

Form Locator 72 a-c.     External cause of injury code (ECI).  (The first E-code should always be printed here.)

Form Locator 73.          Reserved

Form Locator 74.           Principal Procedure Code and Date

Form Locator 74a-e.      Other Procedure Codes and Dates

Form Locator 75.           Reserved

Form Locator 76.           Attending Provider Name and Identifiers

Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier

Secondary Identifier = Contract Number with Payer

Line 2: Attending Physician’s last name, first name. 

Form Locator 77.           Operating Physician Name and Identifier

Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier

Secondary Identifier = Contract Number with Payer

Line 2: Operating Physician’s last name, first name.

Form Locator 78.           Other Provider (Individual) Names and Identifiers

Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier

Secondary Identifier = Contract Number with Payer

Line 2: Other Physician’s last name, first name.

Form Locator 79.           Other Provider (Individual) Names and Identifier

Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier

Secondary Identifier = Contract Number with Payer

Line 2: Other Physician’s last name, first name.

Form Locator 80.           Remarks Field

Form Locator 81 a-d.     Code-Code Field

 

Crosswalk to the HIPAA  005010X223A2 Institutional Implementation Guide

To the greatest degree possible, the electronic crosswalk from the paper form to the electronic conforms to the standard paper form use described above.  However, since there are different data requirements in the electronic format, some deviation does occur.  Specifically, if there is an element that is required on all claims a place has been found on the paper page for it to occur even if there is no formal form locator for its function.

Form Locator to 837I Detail:

Form Locator 1.        Billing Provider Name, Address and Telephone Number.  REQUIRED 

The map described below assumes that the Billing Provider is the same entity as the Pay-to Provider.  If these are different entities than the translator must find a method of sending the Pay-to Provider information in addition to the Billing Provider information. (The address reported is the one that should match the payer’s contract)

      The X12 map:

            Line 1: Provider Name

            2010AA NM103                                                                        

            Line 2: Street Address

            2010AA N301                                                                          

            Line 3: City, State and Zip Code

            2010AA N401,02,03

When all 9 digit postal codes are known they should be sent.                                               

Line 4: Telephone, Fax, Country Code

            2010AA  PER04, 06

            2010AA N404                                                                          

 

Form Locator 2.        Billing Provider Designated Pay-To  Address (Required when different from Form Locator 1)

      The X12 map:

            Line 1: Pay to Name

            not mapped

            Line 2: Street Address or post office box

            2010AB N301

            Line 3: City, State, Zip Code

            2010AB N401,02,03

           

Form Locator 3a.      Patient Control Number   REQUIRED

This number is assigned by the provider to identify this particular claim.  This is an alpha-numeric non-standard field for the providers.  It is strongly recommended that this number be unique for each claim.

      The X12 map:

            2300 CLM01

Form Locator 3b.      Medical/Health Record Number

      The X12 map2

            2300 REF02

Form Locator 4.       Type of Bill – REQUIRED

      Type of Bill is a 4 digit code, leading zeros are not reported in the 837

      The X12 map:

            2300 CLM05-1 (position 12-3 in Form Locator 4)

            2300 CLM05-3 (position 4 in Form Locator 4)

Form Locator 5.        Federal Tax ID Number – REQUIRED

      Provider Tax ID Number [EIN or TIN can be used]   

      The X12 map:

            2010AA REF02

Form Locator 6.        Statement Covers Period(From-Through MMDDYY) REQUIRED

      The X12 map:

            2300 DTP03 (DTP01=434) (CCYYMMDD - CCYYMMDD)

Form Locator 7.        Reserved

Form Locator 8a.    Patient Identifier - REQUIRED

      The X12 Map:

            When Patient = Subscriber

            2010BA NM109

            When Patient is not = Subscriber

            2010CA NM109                       

 

Form Locator 8b.   Patient Name  - REQUIRED

Last and First Name.  Use a comma as the indicator to separate the last and first. No space should be left between a prefix and a name as in MacBeth When using a suffix write: Last Name (space) Suffix, First Name ie Smith III, James

      The X12 map:

            When patient = subscriber:

            2010BA NM103,04,05,07 (Last and First generation respectively)

            When patient is not = subscriber:

            2010CA NM103,04,05,07 (Last and First generation respectively)

Form Locator 9a – e. Patient Address - REQUIRED

It is recommended that address be formatted as (a)street, (b)city, (c)state, (d)zip (e)country

      The X12 map:

            When patient = subscriber:

            2010BA N301: N401,02,03,04 (Street, city, state, ZIP & country respectively)

            When patient is not = subscriber:

            2010CA N301: N401,02,03,04 (Street, city, state, ZIP & country respectively)

Form Locator 10.      Patient Birth Date. (MMDDCCYY[3])  REQUIRED

      The X12 map:

            When patient = subscriber:

            2010BA DMG02 (CCYYMMDD)

            When patient is not = subscriber:

            2010CA DMG02 (CCYYMMDD)

Form Locator 11.      Patient Sex - REQUIRED

      The X12 map:

            When patient = subscriber:

            2010BA DMG03

            When patient is not = subscriber:

            2010CA DMG03

Form Locator 12.      Admission/Start of Care Date (MMDDYY)

      The X12 map:

            2300 DTP03 (DTP01 = 435)

Form Locator 13.      Admission Hour

REQUIRED on inpatient claims, code should be cross walked to appropriate time frame in the 837(see UB04 manual)

      The X12 map:

            2300 DTP03 (DTP01 = 435)

Form Locator 14.      Priority (Type) of Visit - REQUIRED

This is code indicating the priority of the admission/visit.      

      The X12 map:

            2300 CL101

Form Locator 15.      Point of Origin for Admission or Visit - REQUIRED

Source of Referral for Admission or Visit     

      The X12 map:

            2300 CL102

Form Locator 16.      Discharge Hour

REQUIRED on inpatient claims, code should be cross walked to appropriate time frame in the 837(see UB04 manual)                               

      The X12 map:

            2300 DTP03 (DTP01 = 096)

Form Locator 17.      Patient Discharge Status - REQUIRED

      The X12 map:

            2300 CL103

Form Locator 18 – 28. Condition Codes

      The X12 map:

            2300 HI01-2 through HI11-2 (HI01-1 through HI11-1  = BG)

Form Locator 29.      Accident State – REQUIRED for auto accidents

      The X12 map:

            2300 REF02 (REF01=LU)

Form Locator 30.      Reserved 

Form Locator 31 – 34.  Occurrence Code and Date

      The X12 map:

            2300 HI01-2 through HI08-2 (HI01-1 through HI08-1= BH)

            2300 HI01-4 through HI08-4 (HI01-3 through HI08-3=D8)

Form Locator 35 - 36.  Occurrence Span Code and Dates.

      The X12 map:

            2300 HI01-2 through HI04-2 (HI01-1 through HI04-1= BI)

            2300 HI01-4 through HI04-4 (HI01-3 through HI04-3=RD8)

Additional Occurrence Codes can be placed in the Occurrence Span Form Locators utilizing only the From Date. [Payer note: Occurrence and Occurrence Span codes are mutually exclusive.

Form Locator 37.      Reserved

Form Locator 38.   Responsible Party Name and Address

      The X12 map:

            Not mapped

Form Locator 39-41. Value Codes and Amounts

Covered Days, Non-Covered Days, Co-Insurance Days, Life Time Reserve Days are now value codes for the Paper Claim Form

      The X12 map for value codes:

            2300 HI01-2 (HI01-1 through HI12-1= BE) HI01-5 through HI12-5, HI02-2 through HI12-2  

Form Locator 42.      Revenue Codes    REQUIRED

      The X12 map:

            2400 SV201 

Form Locator 43.      Revenue Description (REQUIRED ON PAPER)

      Not cross walked*

*Indicates “not cross walked” but references loops below.  Additionally, 2410 in the 5010 is a Drug Identification.

NDC Reporting:  If a provider is billing using an NDC code (done under contract with a payer), enter the qualifier N4, 11 digit NDC, units qualifier and units on the same line as the REV code and Procedure Code (required when reporting an NDC).  Do not include spaces / dashes 

Compound reporting- should follow the NDC reporting above on consecutive lines

      The X12 map:

            2410 LIN03 = NDC number (LIN02=N4).

            2410 CTP05-1 = Units qualifier (F2, GR, ML, ME, UN)

            2410 CTP04 = Number of units

Form Locator 43.      Line 23 (Line used for page number – paper only)

      Input the page number and total pages  

      Example: Page 3 of 10

      Not cross walked

Form Locator 44.      HCPCS/Accommodation Rates/HIPPS Rate Code Required 

      The X12 map:

            2400 SV202-2 Procedures / HIPPS Rate

            2400 SV202-3,4,5,6 Modifiers

                  The translator vendor must decide on a method to fill the SV202-1 qualifier.

Form Locator 45.      Service Date

      Service Date Required for Outpatient Claims

      The X12 map:

            2400 DTP03 (DTP01=472 Service

Form Locator 45.      Line 23 Creation Date (REQUIRED ON PAPER)

If a multiple page claim is sent the creation date should be reported on all pages

      The X12 map:

            Header BHT04

Form Locator 46.      Service Units / Days - REQUIRED  

      The X12 map:

            2400 SV205

            If the REV code = 0100 - 0219 (accommodation codes) then the qualifier will be for DAYS

            If the REV code = all others then the qualifier will be for UNITS

If there is a need to transmit blood factors which involve International Units, send UNITS; payers will follow up if they think it necessary.

Form Locator 47.      Total Charges (This cannot be a negative number. **)  REQUIRED

      The X12 map for the line level charges:

            2400 SV203

On Paper Line 23 Page Total Charges occurs on the last page of the claim.

      X12 map for the claim level charges

      When Revenue code = 0001, then this value = the value in 2300 CLM02

Form Locator 48.      Non Covered charges (This cannot be a negative number.  **)

      The X12 map:

            2400 SV207

Form Locator 49.      Reserved 

Form Locator 50a - c. Payer Name - At least one is REQUIRED

The A line identifies the primary payer (to the best of the provider’s knowledge), the B line is the secondary payer and the C line is the tertiary payer.  

      The X12 map:

            2010BB NM103 (destination payer name)

            2330B NM103 (non-destination payer name)

The translator vendor must determine a method to indicate the destination payer.  Destination payer is cross walked to the destination payer loops 2010BB loop.  The other two lines are cross walked to the ‘Other Payer’ loop 2330B loop.  See Appendix A for examples.

Form Locator 51.      Health Plan ID Number - REQUIRED

Use the national health plan identifier when established otherwise the number that the health plan has assigned to their particular plans operations.

      The X12 map

            2010BB NM109

            2330B NM109

Form Locator 52a-c. Release of Information Certification Indicator -  One is REQUIRED for each payer

The information for the row marked destination payer (see FL 50) is cross walked to the 2300 loop.  The other two rows are cross walked to the 2320 loop.

      The X12 map:

            2300 CLM09 (for destination payer)

            2320 OI06 (non-destination payers)

Additional Fields required when creating an X12 from a paper claim

Form Locator 52+ (between FL 52 and FL 53).  Medicare Assignment Indicator.  ++ Not Used on Paper Claims

Only used on Medicare claims when Medicare is the destination payer or as required by trading partner agreement. 

      The X12 map:

            2300 CLM07 (output code in small space between FL 52 and FL 53)

Form Locator 53.      Assignment of Benefits Certification indicator - One is REQUIRED for each payer.

The information for the row marked destination payer (see FL 50) is cross walked to the 2300 loop.  The other two rows are cross walked to the 2320 loop.

      The X12 map:

            2300 CLM08 (destination payer line) CLM08 is REQUIRED

            2320 OI03 (non-destination payer line(s)) OI03 is REQUIRED when there is more than one payer on              the claim

Form Locator 54.      Prior Payments - Payer

The information for the row marked destination payer (see FL 50) is cross walked to the 2300 loop.  The other two rows are cross walked to the 2320 loop.

      The X12 map:

            2320 AMT02 (AMT01= D for non-destination payer lines)

Form Locator 55a-c. Estimated Amount Due - Payer

Amount estimated to be due from the indicated payer (estimated responsibility less prior payments)       

      The X12 map:

            2300 AMT02 AMT01= F3

            2320 AMT02 (AMT01= EAF (non-destination payer line(s)) This may be equal to the Patient                         Responsibility from other payers

Form Locator 56.      NPI Billing Provider- REQUIRED

National Provider Identifier

      The X12 Map

            2010AA NM109

Form Locator 57a-c. Other (Billing) Provider ID

This is used for the Billing providers tax ID.

      The X12 Map

            2010AA REF02

Form Locator 58a-c. Insured’s Name - One is REQUIRED for each payer

Use a comma to separate last and first.  No space should be left between a prefix and a name as in MacBeth, VonSchmidt, McEnroe.  The information for the row marked destination payer (see FL 50) is cross walked to the 2010BA loop.  The other two rows are cross walked to the 2330A loop.

      The X12 map:

            Last and First Name:

            2010BA NM103,04,05 (respectively) for destination payer

            Last and First Name:

            2330A NM103,04,05 (respectively) for non-destination payers

Form Locator 59a-c. Patient's Relationship to the Insured - One is REQUIRED for each payer

The information for the row marked destination payer (see FL 50) is cross walked to the 2000B or 2000C loop.  The other two rows are cross walked to the 2320 loop. The translator vendor must determine how to associate the relationship to the correct X12 loop. For destination payers, if the relationship is “self” then map patient information to the 2010BA loop; if the relationship is anything else, then map to 2010CA loop. For the non-destination payer information map to the 2320 loop.

      The X12 map:

            2000B SBR02 (if patient = subscriber, destination payer)

            2000C PAT01 (if patient is not = subscriber, destination payer)

            2320 SBR02 (non-destination payers)

Form Locator 60a-c. Insured’s Unique ID – One is REQUIRED

The insured’s payer-assigned unique ID number.

The information for the row marked destination payer (see FL 50) is cross walked to the 2010BA  or 2010CA loops.  The other two rows are cross walked to the 2330A loop.  If secondary identifiers are sent, the payer must inform the provider which REF01 qualifier to use.  Translator vendors must determine how to convey the correct REF01 qualifier.

      The X12 map:

            2010BA NM109 (subscriber primary identification number for destination payer)

2010BA REF02 (subscriber secondary identification number for destination payer) Separate            primary and secondary numbers with “/” (forward slash).

2330A NM109 (other subscriber primary identification number for non-destination payer)

2330A REF02 (subscriber secondary identification number for destination payer) Separate primary and secondary numbers with “/” (forward slash). 

      The X12 map:

            2010BA Property and Casualty Claim Number

            REF02 (when REF01 = Y4)

Form Locator 61a-c. Insured’s Group Name

The information for the row marked destination payer (see FL 50) is cross walked to the 2000B loop.  The other two rows are cross walked to the 2320 loop.

      The X12 map:

            2000B SBR04 (for destination payer)

            2320 SBR04 (for non-destination payers)

Form Locator 62a-c. Insured’s Group Number

The information for the row marked destination payer (see FL 50) is cross walked to the 2000B loop.  The other two rows are cross walked to the 2320 loop.

     The X12 map:

            2000B SBR03 (for destination payer)

            2320 SBR03 (for non-destination payers)

Form Locator 63a-c. Treatment Authorization Code (Prior Authorization/Referral Number)

The information for the row marked destination payer (see FL 50) is cross walked to the 2300 loop.  The other two rows are cross walked to the 2330 loop.

Output Prior Authorization Number first.  If there is a also a Referral Number, print as shown to the right.  Use a forward slash “ / “ to separate the two numbers if necessary. Use a “ / “ in front of the referral number if that number is sent alone.

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     The X12 map:

            2300 REF02 (for destination payer)  (REF01 = G1 Prior Authorization) (REF01 = 9F Referral)

            2330B REF02 (for non-destination payer) (REF01 = G1 Prior Authorization) (REF01 = 9F Referral)

Form Locator 64a-c. Document Control Number (DCN)

Original control number assigned by the health plan for internal control.  Required for re-priced claims or corrected/replacement or void to previously adjudicated claim.

      The X12 map:

2300 REF02 (for destination payer) F8=qualifier for replacements/voids, 9A or 9C for re-priced claims

            2330B REF02 (for non-destination payer) F8= other payer control number

Form Locator 65a-c. Employer Name (of the insured)

      Not cross walked

Form Locator 66.      Diagnosis and Procedure Code Qualifier (ICD version indicator) - REQUIRED.

For use when 5010 is implemented

      The X12 map:

            2300 HI01-1  

Form Locator 67.      Principal Diagnosis Code and Present on Admission (POA) Indicator- REQUIRED

      The X12 map:

            2300 HI01-9 2 (HI01-1=BK or ABK)

Form Locator 67a-q. position 8 (shaded area)

Report the Present On Admission here        

      The X12 map:

            2300 HI01-9

Form Locator 67a-q. Other Diagnosis codes 

V and E codes are appropriate.

      The X12 map:

            2300 HI01-2 (HI02-1 through HI12-1=BF or ABF) (HI02-2 through HI12-2 = BF or ABF)

Form Locator 68.      Reserved

Form Locator 69.      Admitting Diagnosis Code

      The X12 map:

            2300 HI01-2 (HI01-1=BJ or ABJ)

Form Locator 70a-c. Patient Reason for Visit

Patient reason for visit.

      The X12 map:

            2300 HI01-2 (HI01-1=PR or APR) (HI02-2) (HI03-2)

 

Form Locator 71.      Prospective Payment System (PPS) Code

used to report the DRG.  

      The X12 map:

            2300 HI01-2 (HI01-1=DR)

Form Locator 72a-c. External Cause of Injury (ECI) Code

The ICD diagnosis codes pertaining to external cause of injury

      The X12 map:

            2300 HI01-2 through HI03-2 (HI03-1 = BN or ABN)

            2300 HI01-9 through HI03-9 present on admission (POA)

Form Locator 73.      Reserved

 

Form Locator 74.      Principal Procedure Code and Date

      The X12 map:

            2300 HI01-2 Procedure Code (HI01-1= BR or BBR)

            2300 HI01-4 date

Form Locator 74a-e. Other Procedure Codes and Dates

      The X12 map:

            2300 HI01-2 Code

            (HI01-1 through HI05-1=BQ or BBQ) (HI01-4 through HI05-4 =Date)

            Note: BQ=ICD 9.CM   BBQ= ICD 10.PCS

Form Locator 75.      Reserved

           

Form Locator 76.      Attending Provider Name and ID- Required for all claims except transportation  

Line a: Attending Provider NPI. Followed by Qualifier for Attending Provider Secondary Identifier

Line b: Attending Provider Last and First Name

      The X12 map:

            2310A NM109 NPI. 

            2310A REF01, 02 Secondary Identifier Qualifier, Secondary Identifier

            2310A NM103,04 Last Name, First Name

Form Locator 77.      Operating Provider Name and ID (Primary Surgeon)     

Line a: Operating Provider NPI. Followed by Qualifier for Operating Provider Secondary Identifier

Line b: Operating Provider Last and First Name

      The X12 map:

            2310B NM109 NPI   

            2310B REF01, 02 Secondary Identifier Qualifier, Secondary Identifier

            2310B NM103,04 Last Name, First Name

Form Locator 78-79.  Other Provider Name and ID     

Line a: Other Provider Type Qualifier, Other Provider NPI. Followed by Qualifier for Other Provider Secondary Identifier

Line b: Other Provider Last and First Name

Other Provider Type Qualifiers include: DN=referring provider, ZZ=other operating physician,82=rendering provider

      The X12 map:

            2310C NM109 NPI.  (When NM101=ZZ)

            2310C REF01, 02 Secondary Identifier Qualifier, Secondary Identifier

            2310C NM103,04 Last Name, First Name

 

            2310D NM109 =NPI   (When NM101=82)

            2310D REF01, 02 Secondary Identifier Qualifier, Secondary Identifier

            2310D NM103,04 Last Name, First Name

 

            2310F NM109 =NPI  (When NM101=DN)

            2310F REF01, 02 Secondary Identifier Qualifier, Secondary Identifier

            2310F NM103,04 Last Name, First Name

Form Locator 80.      Remarks 

      The X12 map:

            2300 NTE01 (Qualifier)

            2300 NTE02 (Notes). 

Form Locator 81a-d. Code-Code (Paper only)

This is where you can put additional codes required if not enough space in designated form locator ie condition codes, occurrence codes, value code span. 

 X12 Allows for more codes than paper and are indicated in the crosswalk above.

Providers should report Taxonomy codes if required by Payer contracts

Billing Providers Taxonomy code. (B3=Taxonomy)

Example: B3 282N0000X

      The X12 map:

            2000A PRV03 when PRV01=BI                                              

Attending Providers Taxonomy code (used by some government /Medicaid payers)

      The X12 map:

            2310A PRV03 when PRV02=ZZ 

Attachment control number (see valid code list in UB-04 manual 2010 version or later)

      The X12 map:

            2300 PWK06

Implementation Date: January 1, 2012 or with implementation of 5010

 

History: (MM/DD/YY)

 

Original V.1

A* 1

V.2

A* 1

A* 2

V 3.0

A* 4

ORIGINATION DATE

12/04/94

01/14/98

7/02

03/14/06

05/17/07

05/18/10

 

APPROVAL DATE

02/09/95

08/10/99

06/12/03

02/07/07

08/06/08

5/18/2011

 

EFFECTIVE DATE

03/09/95

09/10/99

07/12/03

03/07/07

09/06/08

6/18/2011

 

* A = Amendment

 

 

     [1] Utah Uniform Billing Instruction Manual, Utah Hospital Association, April 16, 1993.

     [2] Available at the Washington Publishing Company web site, http::/www.wpc-edi.com

[3] MMDDCCYY is the format to print the date on the UB04 paper form.

 

 

APPENDIX A

UB04 Paper Claim Examples

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