UB04 data field requirements Field location UB04 Description Inpatient Outpatient 1 Provider Name and Address Required Required 49 Future Use NA NA 50 Payer Name Required Required 51 Health Plan ID Situational Situational 52 Release of Information Certification Required Required Identify the section in the provider manual related to UB04 claim form completion Outline DiagnosisRelated Groups (DRG) reimbursement requirements (Box 42) to the right border of Box 49.
Enter the correct billing information on another detail line. through the entire detail line from the Box 49 on ub04 manual border of Revenue Code field (Box 42) to the right border of the Unlabeled field (Box 49). Enter the correct billing information on another detail line.
Be sure to use only a blue or black ballpoint pen. National Uniform Billing Committee Official U B04 Data Specifications Manual 2016 FL 49 Reserved for Assignment by the NUBC 176 FL 50 Payer Name 177 FL 51 Payer IDHealth Plan ID 178 FL 52 Release of Information Certification Indicator 179 CMS Manual System Department of Health& Human Services (DHHS) Pub Medicare Claims Processing Centers for Medicare& Medicaid Services (CMS) Transmittal 1104 Date: NOVEMBER 3, Medicare Claims Processing Manual.
Chapter 25 Completing and Processing the Form CMS1450 Data Set. Table of Contents (Rev. 3709, ) Transmittals for Chapter 25 the information in the AHA Uniform Billing Manual for the UB04. NOTE: This chapter applies to paper UB04 claims submitted to AHCCCS. For information on HIPAAcompliant 837 transactions, please consult the appropriate Implementation Guide. Companion UB04 \(CMS 1450\) Tips for Completing the UB04 (CMS1450) Claim Form Page 4 of 17 Field Field description Field type Instructions 42 Revenue code Required Use this field to report the 49 Reserved for Assignment by the NUBC Not Required NA 50a, b, c Payer Name Conditional If more than Form locator 17: Discharge status using the twodigit codes from the NUBC manual.
Form locator 1828: Condition codes using the twodigit codes from the NUBC manual for up to 11 occurrences. Form locator 29: Accident state (if applicable) using twodigit state code The UB04 Data Specifications Manual (the UB04 Manual) is protected under federal National Uniform Billing Committee UB04 Official Data Specifications Manual 2015 FL 49 Reserved for Assignment by the NUBC 176 FL 50 Payer Name 177 FL 51 Payer IDHealth Plan ID 178 Blue Shield of New Mexico offers this guide for completion of the UB04 form for your patients with (facility) coverage.
For information on the UB04 billing form, or to obtain an Official UB04 Data Specifications Manual, visit the National Uniform Billing Committees Official UB04 Data Specifications Manual. 49. Reserved for UB04 CLAIM FORM INSTRUCTIONS.
FIELD NUMBER FIELD NAME INSTRUCTIONS 1. Billing Provider Name& Address manual for specific codes. In the Amount box, enter the number, amount, or. UCR value associated with that code.