UB form Feilds and Descriptions
Box : 39-41
Field :Value Codes
Description : For Medicare Part A and B claims, enter the appropriate value code(s) for Medicare
Coinsurance and Deductible when Medicare is the primary payer. When Medicare coverage is
present, it will normally be reported as “Payer A” on the UB-04. Value codes are then reported as follows:
• A1 (Deductible Payer A) – For the Part A or Part B
deductible amount
• A2 (Coinsurance Payer A) – For Part A or Part B
coinsurance amounts.
However, in situations where Medicare is “Payer B”,
use Value Codes “B1” and “B2” to report Medicare
coinsurance and deductible.
Failure to correctly report the Medicare deductible
may result in incorrect payment, suspended claims, or
denied claims.
39-41 Value Codes For hospice services, enter code “61” and the Cost-Based Statistical Area (CBSA) code for your service/county as a dollar amount. Refer to the “Hospice rates” table of the Hospice Services Supplemental Information guide for CBSA codes.
Box : 42
Feild : Revenue Codes
Description : Enter the four (4)-digit code that most accurately describes the service provided.
For a complete list of Revenue Center Codes for your provider type, refer to your program’s Supplemental Information handbook. Enter “0001” in line 23 of this field to indicate
the claim’s total charges (entered in FL 47).
Box : 44
Feild : HCPCS/Rates
Description : Enter the five (5)-digit code for each Revenue Center Code requiring CPT/HCPCS. Refer to the “Revenue Center Code Table” or rate information in your program’s Supplemental Information handbook for revenue codes requiring CPT/HCPCS.
• Inpatient hospital services do not require CPT/HCPCS.
Box : 45
Feild : Service Dates
Description : For all nursing facility claims, enter Creation Date on line 23 (MMDDYYYY): Enter the date the bill was created or prepared for submission. Report this date on all pages of the UB-04.
Box : 46
Feild : Service Units
Description : Enter total days or units of service for each Revenue Center Code listed.
• One visit equals one unit of service.
• One supply item equals one unit of service.
Notes for nursing facilities:
• The total number of units must not exceed the total number of days in the “Statement Covers Period” in FL 6.
• NOTE: Any time there is a Break in Service, you must submit a new UB-04.
Box : 47
Feild : Total Charges
Description : Enter the usual and customary charge for each Revenue Center Code listed. Enter the sum of all charges in line 23 of this field.
Box : 50
Feild : Payer Identification
Description : Enter the name(s) of the payer organizations you are billing (up to three payers).
• Enter Medicaid on Line C.
• Medicaid is the payer of last resort. Any resources billed prior to billing Medicaid should be listed first.
Box : 54
Feild : Prior Payments
Description : Enter the actual amount of any payments you received from Third Party Resources (TPR).
• If Medicare paid, show the actual Medicare payment.
• Do not list write-offs, what Medicaid previously paid, or copayments.
Box : 56
Feild : NPI
Description : Enter your ten (10)-digit National Provider Identifier.
Box : 57
Feild : Other Provider ID
Description : Enter your six (6)- or nine (9)-digit DHS provider number on line C. DHS will pay this provider. Do not enter other numbers (e.g., Medicare).
Box : 60
Feild : Insured’s Unique ID
Description : Use the eight (8)-digit Client ID Number. The number is printed on the Medical Care ID. It can also be obtained through the Automated Voice Response (AVR) or the provider web portal.
Box : 63
Field : Treatment Authorization Codes
Description : If the service was prior authorized, enter the ten (10)-digit Prior Authorization number that DHS issued for the service on line C.
• For all services except inpatient hospital: DO NOT bill prior-authorized and non-authorized
services on the same claim form. You must submit separate UB claim forms.
• Bill all inpatient hospital services (both priorauthorized and non-authorized) on a single claim.
Box : 67
Field : Principal Diagnosis Code
Description : Enter the primary diagnosis/condition of the recipient by entering the current ICD-9-CM code. The diagnosis code must be the reason chiefly responsible for the service being provided as shown in the medical records.
• Carry out code to its highest degree of specificity.
• DO NOT enter the decimal point.
Box : 67A – 67D
Field : Other Diagnosis Codes
Description : Enter up to four (4) additional ICD-9-CM codes, as appropriate. You can enter additional diagnosis codes for conditions that:
• Coexist at the time of admission.
• Develop subsequently.
• Affect treatment received and/or length of treatment.
Box : 69
Field : Admit Diagnosis
Description : For nursing facility services, enter the admitting diagnosis/condition of the resident by entering the ICD-9-CM code.
Box : 76
Field : Attending Physician ID
Description : For nursing facility services, enter the ten (10)-digit NPI followed by the six (6)-digit DHS provider number for the resident’s attending physician (primary care physician).
Box : 78
Field : Other Physician ID
Description : For Primary Care Manager (PCM) clients, list the ten (10)-digit NPI, followed by the six (6)- digit DHS provider number of the PCM.
Box : 80
Field : Remarks
Description : If the recipient has other medical coverage, enter the appropriate two (2)-digit third party resource (TPR) explanation code.
Please see the previout for introduction section
