| (S) value code and amounts (UB-04, fields 39 - 41) are required for inpatient admissions. If no value codes are applicable to the inpatient admission, the provider may enter value code 01; (T) revenue code (UB-04, field 42) is required; (U) revenue description (UB-04, field 43) is required; (V) HCPCS/Rates (UB-04, field 44) are required if Medicare is a primary or secondary payor; (W) service date (UB-04, field 45) is required if the claim is for outpatient services; (X) date bill submitted (UB-04, field 45, line 23) is required; (Y) units of service (UB-04, field 46) are required; (Z) total charge (UB-04, field 47) is required; (AA) HMO or preferred provider carrier name (UB-04, field 50) is required; (BB) prior payments-payor (UB-04, field 54) are required if payments have been made to the physician or provider by a primary plan as required by subsection (d) of this section; (CC) for claims filed or re-filed on or after May 23, 2008, the NPI number of the billing provider (UB-04, field 56) is required if the billing provider is eligible for an NPI number; (DD) other provider number (UB-04, field 57) is required if the HMO or preferred provider carrier, prior to June 17, 2003, required provider numbers and gave notice of that requirement to physicians and providers; (EE) subscriber's name (UB-04, field 58) is required if shown on the patient's ID card; (FF) patient's relationship to subscriber (UB-04, field 59) is required; (GG) patient's/subscriber's certificate number, health claim number, ID number (UB-04, field 60) is required if shown on the patient's ID card; (HH) insurance group number (UB-04, field 62) is required if a group number is shown on the patient's ID card; (II) verification number (UB-04, field 63) is required if services have been verified pursuant to §19.1724 of this title. If no verification has been provided, treatment authorization codes (UB-04, field 63) are required when authorization is required and granted; (JJ) principal diagnosis code (UB-04, field 67) is required; (KK) diagnoses codes other than principal diagnosis code (UB-04, fields 67A - 67Q) are required if there are diagnoses other than the principal diagnosis; (LL) admitting diagnosis code (UB-04, field 69) is required; (MM) principal procedure code (UB-04, field 74) is required if the patient has undergone an inpatient or outpatient surgical procedure; (NN) other procedure codes (UB-04, fields 74 - 74e) are required as an extension of subparagraph (MM) of this paragraph if additional surgical procedures were performed; (OO) attending physician NPI number (UB-04, field 76) is required on or after May 23, 2008, if attending physician is eligible for an NPI number; and (PP) attending physician ID (UB-04, field 76, qualifier portion) is required. (4) Required form and data elements for institutional providers for claims filed or re-filed before July 18, 2007. The UB-92 CMS-1450 and the data elements described in this paragraph are required for claims filed or re-filed by institutional providers before July 18, 2007. The UB-92 CMS-1450 must be completed in accordance with the special instructions applicable to the data element as described in this paragraph for clean claims filed by institutional providers. However, upon notification that an HMO or preferred provider carrier will accept claims filed or re-filed on form UB-04 CMS-1450, an institutional provider may submit claims on form UB-04 CMS-1450 prior to the subsection (b)(3) mandatory use date, subject to the subsection (b)(3) required data elements. (A) provider's name, address and telephone number (UB-92, field 1) is required; (B) patient control number (UB-92, field 3) is required; (C) type of bill code (UB-92, field 4) is required and shall include a "7" in the third position if the claim is a corrected claim; (D) provider's federal tax ID number (UB-92, field 5) is required; (E) statement period (beginning and ending date of claim period) (UB-92, field 6) is required; (F) covered days (UB-92, field 7) is required if Medicare is a primary or secondary payor; (G) noncovered days (UB-92, field 8) is required if Medicare is a primary or secondary payor; (H) coinsurance days (UB-92, field 9) is required if Medicare is a primary or secondary payor; (I) lifetime reserve days (UB-92, field 10) is required if Medicare is a primary or secondary payor and the patient was an inpatient; (J) patient's name (UB-92, field 12) is required; (K) patient's address (UB-92, field 13) is required; (L) patient's date of birth (UB-92, field 14) is required; (M) patient's gender (UB-92, field 15) is required; (N) patient's marital status (UB-92, field 16) is required; (O) date of admission (UB-92, field 17) is required for admissions, observation stays, and emergency room care; (P) admission hour (UB-92, field 18) is required for admissions, observation stays, and emergency room care; (Q) type of admission (e.g., emergency, urgent, elective, newborn) (UB-92, field 19) is required for admissions; (R) source of admission code (UB-92, field 20) is required; (S) discharge hour (UB-92, field 21) is required for admissions, outpatient surgeries, or observation stays; (T) patient-status-at-discharge code (UB-92, field 22) is required for admissions, observation stays, and emergency room care; (U) condition codes (UB-92, fields 24 - 30) are required if the CMS UB-92 manual contains a condition code appropriate to the patient's condition; (V) occurrence codes and dates (UB-92, fields 32 - 35) are required if the CMS UB-92 manual contains an occurrence code appropriate to the patient's condition; (W) occurrence span code, from and through dates (UB-92, field 36), are required if the CMS UB-92 manual contains an occurrence span code appropriate to the patient's condition; (X) value code and amounts (UB-92, fields 39-41) are required for inpatient admissions. If no value codes are applicable to the inpatient admission, the provider may enter value code 01; (Y) revenue code (UB-92, field 42) is required; (Z) revenue description (UB-92, field 43) is required; (AA) HCPCS/Rates (UB-92, field 44) are required if Medicare is a primary or secondary payor; (BB) Service date (UB-92, field 45) is required if the claim is for outpatient services; (CC) units of service (UB-92, field 46) are required; (DD) total charge (UB-92, field 47) is required; (EE) HMO or preferred provider carrier name (UB-92, field 50) is required; (FF) provider number (UB-92, field 51) is required if the HMO or preferred provider carrier, prior to June 17, 2003, required provider numbers and gave notice of that requirement to physicians and providers. (GG) prior payments-payor and patient (UB-92, field 54) are required if payments have been made to the physician or provider by the patient or another payor or subscriber, on behalf of the patient or subscriber, or by a primary plan as required by subsection (d) of this section; (HH) subscriber's name (UB-92, field 58) is required if shown on the patient's ID card; (II) patient's relationship to subscriber (UB-92, field 59) is required; (JJ) patient's/subscriber's certificate number, health claim number, ID number (UB-92, field 60) is required if shown on the patient's ID card; (KK) insurance group number (UB-92, field 62) is required if a group number is shown on the patient's ID card; (LL) verification number (UB-92, field 63) is required if services have been verified pursuant to §19.1724 of this title. If no verification has been provided, treatment authorization codes (UB-92, field 63) are required when authorization is required and granted; (MM) principal diagnosis code (UB-92, field 67) is required; (NN) diagnoses codes other than principal diagnosis code (UB-92, fields 68 - 75) are required if there are diagnoses other than the principal diagnosis; (OO) admitting diagnosis code (UB-92, field 76) is required; (PP) procedure coding methods used (UB-92, field 79) is required if the CMS UB-92 manual indicates a procedural coding method appropriate to the patient's condition; (QQ) principal procedure code (UB-92, field 80) is required if the patient has undergone an inpatient or outpatient surgical procedure; Cont'd... |
