EDI UB-04 Claims Procedures (Security Health Plan)
EDI UB-04 Claims processing procedures: EDI UB-04 Claims completion for inpatient and outpatient services billed by hospitals, skilled nursing facilities, home health agencies and other institutional providers (Continuation).
51. Health plan ID – Providers’ current Medicare Provider Number.
52. Release of information certification indicator – This field indicates whether the provider has on file a signed statement from the beneficiary permitting the provider to release data to other organizations in order to adjudicate the claim. (Required)
53. Assignment of benefit certification indicator – This field shows whether the provider has a signed form authorizing the third-party insurer to pay the provider directly for the service.
54. Prior payments – payers and patient – The amount the hospital has received toward payment of this bill prior to the billing date for the payer indicated in field 50 on lines a., b., and c. for outpatient claims and all other third-party payers. (Required)
55. Estimated amount due – An estimate by the hospital of the amount due from the indicated payer in field 50 on lines a., b., and c., or from the patient (estimated responsibility less any prior payments).
56. NPI – National Provider Identifier (Type 2 for organization required).
57. Other Provider ID – This field is not used for provider reporting. For National use only.
58. Insured’s name – Name of the patient or insured individual in whose name the insurance is issued as qualified by the payer organization listed in field 50 on lines a., b., and c. (Required)
59. Patient’s relationship to insured – This field contains the code that indicates the relationship of the patient to the insured individuals identified in field 58 on lines a., b., and c. (Required) when Medicare is the secondary or tertiary payer.
60. Certificate/Social Security Number/health insurance claim/identification number – The insured’s identification number assigned by the payer organization. This field allows 19 alphanumeric characters in three lines. (Required)
61. Insured group name – The group or plan through which the health insurance coverage is provided to the insured. (Required)
62. Insurance group number – The identification number, control number or code that is assigned by the insurance company or claims administrator to identify the group under which the individual is covered.
63. Treatment authorization codes – A number or other indicator that designates that the treatment covered by this bill has been authorized by the payer indicated in field 50 on lines a., b., and c. (Required)
64. Document control number – Not required.
65. Employer name of the insured – Name of the employer that provides health care coverage for the insured individual identified in field 58 on lines a., b., and c. This field allows for 24 alphanumeric characters on each of three lines. (Required)
UB-04 Claims Processing Procedures (Part 1)