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:
- Explanations of the use of each form locator are given in the UB04
- Explanations regarding the use of the ASC X12 data elements are given in the ASC X12 837 005010X223A2 implementation guide.
- If a Box is marked “Not cross walked” this means that this data element is not carried in the implementation guide.
- 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.
- 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.
- 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:
- This Standard shall be implemented with the implementation of the HIPAA 5010 Institutional implementation guide.
- 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
- 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.
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
Click below to download a copy of this document.
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