Claims Processing Procedures: UB-04 Security Health Plan
Claims processing procedures: UB-04 claim completion for inpatient and outpatient services billed by hospitals, skilled nursing facilities, home health agencies and other institutional providers (Continuation).
37. Unlabeled
38. Subscriber name and address – The name and address of the party responsible for the bill. This information must be accurate.
39. – 41. Value codes and amounts – Contain codes and the related dollar amounts identifying monetary data required for processing claims. The information is required for benefit determination and provides reporting capability for data elements that are used routinely but do not warrant a separate field assignment.
42. Revenue code – Use this field to report the appropriate numeric code corresponding to each narrative description or standard abbreviation that identifies a specific accommodation and/or ancillary service. Revenue 001 must be the final entry on all bills. (Required)
43. Revenue description – A narrative description or standard abbreviation for each revenue code category reported on the UB-04 claim form.
44. HCPCS/rates/HIPPS rate codes – The Healthcare Common Procedure Coding System (HCPCS) applicable to ancillary services for outpatient claims, the HIPPS rate code or the accommodation rate for inpatient claims. (For outpatient claims, HCPCS procedure codes are required.)
45. Service date – The date on which the indicated service was provided. This field is required for billing outpatient Medicare claims.
46. Service units – A quantitative measure of services rendered, by revenue category, to or for the patient, including items such as the number of accommodation days, visits, miles, pints of blood, units of treatments. (Required for Medicare billing.)
47. Total charges – The total charges pertaining to the related revenue code for the current billing period as entered in the Statement Covers Period field, including both covered and noncovered charges. (Required)
48. Noncovered charges – The total noncovered charges for the primary payer pertaining to a particular revenue code. (Required)
49. Unlabeled field – This is not used for provider reporting. For National use only.
50. Payer identification – The name and, if required, the number identifying each payer organization from which the provider might expect some payment for the bill. Line 50 a. is used to report the primary payer, line 50 b. secondary payer, if applicable, and line 50 c. for the tertiary payer. (Required)