What is Box 39 on ub04?
Box 39-41; a-d – Value codes and amounts: (Optional) Use these locators to indicate codes and amounts essential to the proper adjudication of the submitted claim. Each form locator contains a three digit field in which to key the indicator code, and a larger free text field in which to designate an applicable amount.
What is Box 81 on ub04?
Billing Tip: Enter code “81” when billing for emergency services, or the claim may be reduced or denied. An Emergency Certification Statement must be attached to the claim or entered in the Remarks field (Box 80).
What goes in box 59 on ub04?
Patient’s Relation to Insured
59. Patient’s Relation to Insured Enter the code for the patient’s relationship to the insured. 60. Insured’s Unique Identifier Enter recipient’s nine-digit Medical Assistance ID.
What is Box 53 on ub04?
Form Locator 53: Assignment of benefits (a) Primary, (b) Secondary, and (c) Tertiary. Form Locator 54: Prior payments (a) Primary, (b) Secondary, and (c) Tertiary. Form Locator 55: Estimated amount due (a) Primary, (b) Secondary, and (c) Tertiary. Form Locator 56: Billing provider national provider identifier (NPI).
What is Box 42 on ub04?
42 Required Required Revenue Code – For inpatient billing, enter the four- digit revenue code for the services provided, e.g. room and board, obstetrics, etc. 43 Required Required Revenue Description – Identify the description of the particular revenue code in box 42 or HCPCS code in box 44.
What is Field 17 on a ub04?
17. * Patient Status Enter the 2-digit patient status code that best describes the patient’s discharge status. 05-Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution.
What is Box 38 on a ub04?
38 Responsible Party Name and Address Required This field is for reporting the name and address of the person responsible for the bill. 39 – 41 Value Codes and Amounts Conditional These fields contain the codes and related dollar amounts to identify the monetary data for processing claims.
What is value code 80 on ub04?
The number of covered days (value code 80) must match the number of units and charges reported for the covered room and board days. Claims to be paid by Per Diem reimbursement should have the appropriate covered days reported to match the authorization.
What is Box 17 on a ub04?
What are form locators in UB-04?
The fields in UB-04 are called “Form Locator” and from 18-28 form locators are further divided into situations identified by sub-codes referring the situation. The NUBC lists 99 situations with numeric codes start from 01-99.
How do I contact the UB-04 claim center?
If you have any questions regarding the UB-04 claim form, the NPI application process, or reporting your NPI to us, please call your Network Coordinator or Hospital/Ancillary Services Coordinator or contact Customer Service at 1-800-275-2583. UB-04 data field requirements
What are the form locators 43 and 44?
Form locator 43: Revenue code description, investigational device exemption (IDE) number, or Medicaid drug rebate NDC (national drug code) Form locator 44 : HCPCS (Healthcare Common Procedure Coding System), accommodation rates, HIPPS (health insurance prospective payment system) rate codes
What are form locators 4 and 5?
Form Locator 4: Type of Bill (TOB). This is a four-digit code beginning with zero, according to the National Uniform Billing Committee guidelines. Form Locator 5: Federal tax number for your facility.