| (CC) procedure/modifier code (CMS-1500 (08/05), field
24D) is required;
(DD) diagnosis code by specific service (CMS-1500 (08/05),
field 24E) is required with the first code linked to the applicable
diagnosis code for that service in field 21;
(EE) charge for each listed service (CMS-1500 (08/05),
field 24F) is required;
(FF) number of days or units (CMS-1500 (08/05), field
24G) is required;
(GG) the NPI number of the rendering physician or provider
(CMS-1500 (08/05), field 24J, unshaded portion) is required if the
rendering provider is not the billing provider listed in CMS-1500
(08/05), field 33, and if the rendering physician or provider is eligible
for an NPI number;
(HH) physician's or provider's federal tax ID number
(CMS-1500 (08/05), field 25) is required;
(II) whether assignment was accepted (CMS-1500 (08/05),
field 27) is required if assignment under Medicare has been accepted;
(JJ) total charge (CMS-1500 (08/05), field 28) is required;
(KK) amount paid (CMS-1500 (08/05), field 29) is required
if an amount has been paid to the physician or the provider submitting
the claim by the patient or subscriber, or on behalf of the patient
or subscriber or by a primary plan to comply with subparagraph (Q)
of this paragraph and as required by subsection (d) of this section;
(LL) signature of physician or provider or a notation
that the signature is on file with the MCC (CMS-1500 (08/05), field
31) is required;
(MM) name and address of the facility where services
were rendered, if other than home, (CMS-1500 (08/05), field 32) is
required;
(NN) the NPI number of the facility where services
were rendered, if other than home, (CMS-1500 (08/05), field 32a) is
required if the facility is eligible for an NPI;
(OO) physician's or provider's billing name, address,
and telephone number (CMS-1500 (08/05), field 33) is required;
(PP) the NPI number of the billing provider (CMS-1500
(08/05), field 33a) is required if the billing provider is eligible
for an NPI number; and
(QQ) provider number (CMS-1500 (08/05), field 33b)
is required if the MCC required provider numbers and gave notice of
the requirement to physicians and providers before June 17, 2003.
(3) Required form and data elements for institutional
providers. The UB-04 claim form and the data elements described in
this paragraph are required for claims filed or refiled by institutional
providers. The UB-04 claim form must be completed under the special
instructions applicable to the data elements as described by this
paragraph for clean claims filed by institutional providers.
(A) provider's name, address, and telephone number
(UB-04, field 1) are required;
(B) patient control number (UB-04, field 3a) is required;
(C) type of bill code (UB-04, field 4) is required
and must include a "7" in the fourth position if the claim is a corrected
claim;
(D) provider's federal tax ID number (UB-04, field
5) is required;
(E) statement period (beginning and ending date of
claim period) (UB-04, field 6) is required;
(F) patient's name (UB-04, field 8a) is required;
(G) patient's address (UB-04, field 9a - 9e) is required;
(H) patient's date of birth (UB-04, field 10) is required;
(I) patient's sex (UB-04, field 11) is required;
(J) date of admission (UB-04, field 12) is required
for admissions, observation stays, and emergency room care;
(K) admission hour (UB-04, field 13) is required for
admissions, observation stays, and emergency room care;
(L) type of admission (such as emergency, urgent, elective,
newborn) (UB-04, field 14) is required for admissions;
(M) point of origin for admission or visit code (UB-04,
field 15) is required;
(N) discharge hour (UB-04, field 16) is required for
admissions, outpatient surgeries, or observation stays;
(O) patient discharge status code (UB-04, field 17)
is required for admissions, observation stays, and emergency room
care;
(P) condition codes (UB-04, fields 18 - 28) are required
if the CMS UB-04 manual contains a condition code appropriate to the
patient's condition;
(Q) occurrence codes and dates (UB-04, fields 31 -
34) are required if the CMS UB-04 manual contains an occurrence code
appropriate to the patient's condition;
(R) occurrence span codes and from and through dates
(UB-04, fields 35 and 36) are required if the CMS UB-04 manual contains
an occurrence span code appropriate to the patient's condition;
(S) value code and amounts (UB-04, fields 39 - 41)
are required for inpatient admissions, and may be entered as value
code "01" if no value codes are applicable to the inpatient admission;
(T) revenue code (UB-04, field 42) is required;
(U) revenue description (UB-04, field 43) is required;
(V) Healthcare Common Procedure Coding System (HCPCS)
codes or 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) MCC name (UB-04, field 50) is required;
(BB) prior payments-payor (UB-04, field 54) are required
if payments have been made to the provider by a primary plan as required
by subsection (d) of this section;
(CC) 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, before 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 or subscriber's certificate number,
health claim number, and ID number (UB-04, field 60) are 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 under §19.1719 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) diagnosis 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 if the attending physician is eligible for an NPI number;
and
(PP) attending physician ID (UB-04, field 76, qualifier
portion) is required.
(c) Required data elements for dental claims. The data
elements described in this subsection are required as indicated and
must be completed or provided under the special instructions applicable
to the data elements for nonelectronic clean claims filed by dental
providers with HMOs.
(1) patient's name is required;
(2) patient's address is required;
(3) patient's date of birth is required;
(4) patient's sex is required;
(5) patient's relationship to subscriber is required;
(6) subscriber's name is required;
(7) subscriber's address is required, but the provider
may enter "Same" if the subscriber's address is the same as the patient's
address required by paragraph (2) of this subsection;
(8) subscriber's date of birth is required, if shown
on the patient's ID card;
(9) subscriber's sex is required;
Cont'd... |
