Claims Forms - UB Flashcards
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| 7288758361 | UB CLAIM | IP AND OP HOSPITAL. CRITICAL ACCESS HOSPITALS AND COMPREHENSIVE REHAB FACILITIES. FL IS A FORM LOCATOR | 0 | |
| 7288765479 | FL1 | BILLING PROVIDERS NAME, ADDRESS AND # | 1 | |
| 7288767076 | FL2 | BILLING PROVIDERS DESIGNATED PAY TO NAME, ADDRESS AND SECONDARY IDENTIFICATION FLS. FLS ARE NOT REQUIRED. | 2 | |
| 7288772523 | FL3A | PATIENT CONTROL NUMBER. ACCOUNT NUMBER AKA. | 3 | |
| 7288774628 | FL3B | MEDICAL RECORD NUMBER. ASSIGNED BY FACILITY | 4 | |
| 7288778362 | FL4 | TYPE OF BILL. 4 DIGIT NUMBER. STARTS WITH A LEADING 0 | 5 | |
| 7288782539 | TYPE OF BILL SEQUENCE | 1ST DIGIT IS 0- CMS IGNORES 2ND DIGIT IS TYPE OF FACILITY - TYPE OF FACILITY 3RD DIGIT IS BILL CLASSIFICATION - TYPE OF CARE 4TH DIGIT IS FREQUENCY -INDICATED SEQUENCE OF BILL IN THIS EPISODE OF CARE | 6 | |
| 7288800499 | FL5 | TAX ID NUMBER | 7 | |
| 7288804404 | FL6 | FROM THROUGH DATES. MMDDYY | 8 | |
| 7288806766 | FL7 | NOT USED | 9 | |
| 7288806767 | FL8 | PATIENT NAME/ID | 10 | |
| 7288809364 | FL9 | PATIENTS ADDRESS | 11 | |
| 7288809365 | FL10 | DOB MMDDCCYY | 12 | |
| 7288810532 | FL11 | PATIENT SEX. M OR F | 13 | |
| 7288811990 | FL12 | ADMISSION START OF CARE DATE. REQUIRED FOR INPATIENT AND HOME HEALTH | 14 | |
| 7288814787 | FL13 | ADMISSION HOUR. NOT REQUIRED | 15 | |
| 7288814788 | FL14 | PRIORITY TYPE OF ADMISSION OR VISIT. | 16 | |
| 7288817507 | FL15 | POINT OF ORIGIN FOR ADMISSION OR VISIT. SOUR OF THE REFERRAL FOR THIS VISIT. EX: 7 INDICATED ER | 17 | |
| 7288822374 | FL16 | DISCHARGE HOUR. NOT REQUIRED | 18 | |
| 7288822375 | FL17 | PATIENT DISCHARGE STATUS. 01 MEANS DISCHARGE TO HOME OR SELF CARE | 19 | |
| 7288824989 | FL18-28 | CONDITION CODES | 20 | |
| 7288827707 | FL29 | ACCIDENT STATE. NOT USED | 21 | |
| 7288828885 | FL30 | UNTITLED. NOT USED | 22 | |
| 7288830593 | FL 31-34 | OCCURRENCE CODES AND DATES. EVENT CODES ARE 2 ALPHA-NUMERIC DIGITS AND DATES ARE 6 NUMERIC DIGITS MMDDYY WHEN OCCURRENCE CODES 01-04 AND 24 ARE USED THE PROVIDER MUST MAKE SURE THE ENTRY INCLUDES THE APPROPRIATE VALUE CODE IN FLS 39-41 IF ANOTHER PAYER IS INVOLVED | 23 | |
| 7288843970 | FL35-36 | SPAN CODES AND DATES. INPATIENT ONLY | 24 | |
| 7288846019 | FL37 | NOT USED | 25 | |
| 7288846020 | FL38 | RESPONSIBLE PARTY NAME AND ADDRESS. NOT USED | 26 | |
| 7288848098 | FL39-41 | VALUE CODES AND AMOUNTS. 2 ALPHA NUMERIC DIGITS. NO NEGATIVE AMTS EXCEPT FL41. | 27 | |
| 7288858189 | FL42 | REV CODES | 28 | |
| 7288863739 | FL43 | REV CODE DESCRIPTION. NOT REQUIRED | 29 | |
| 7288868172 | FL44 | HCPCS/FOR OUTPATIENT ENTER CPT AND HCPCS LEVEL 2. UP TO FOUR MODIFIERS | 30 | |
| 7288871711 | FL45 | SERVICE DATE. | 31 | |
| 7288874709 | FL46 | UNITS OF SERVICE | 32 | |
| 7288876580 | FL47 | TOTAL CHARGES | 33 | |
| 7288876581 | FL48 | NON COVERED CHARGES. | 34 | |
| 7288879049 | FL49 | NOT USED | 35 | |
| 7288879050 | FL50 | PAYER ID. IF MC IS PRIMARY, PROVIDER MUST ENTER MEDICARE ON LINE A. LISTING MC IS SAYING THAT MC IS PRIMARY. IF OTHER INSURANCE IS PRIMARY ENTER ON LINE A AND THEN PUT MC ON LINE B OR C AS APPROPRIATE | 36 | |
| 7288886547 | FL51 A-C | HEALTH PLAN ID. REPORT THE NPI | 37 | |
| 7288888133 | FL 52A, B AND C | RELEASE OF INFORMATION CERTIFICATION INDICATOR. Y MEANS SOF TO RELEASE DATA. I CODE MEANS INFORMED CONSENT TO RELEASE MEDICAL INFO. REQUIRED WHEN DR HAS NOT COLLECTED A SIGNATURE AND STATE/FEDERAL LAWS DO NOT SUPERSEDE THE HIPPA RULE | 38 | |
| 7288899454 | FL 53A, B AND C | ASSIGNMENT OF BENEFITS. NOT USED. | 39 | |
| 7288900931 | FL 54 A B AND C | PRIOR PAYMENT..ALL SERVICES BESIDES INPATIENT OR SNF. DEDUCTIBLES OR COPAYS | 40 | |
| 7288907978 | FL55 A, B AND C | ESTIMATED AMT DUE FROM PT. NOT REQUIRED | 41 | |
| 7288909796 | FL 56 | NPI | 42 | |
| 7288911154 | FL 57 | NOT USED | 43 | |
| 7288911155 | FL 58 A, B AND C | INSURED'S NAME. | 44 | |
| 7288913073 | FL 59 A, B AND C | PT'S RELATIONSHIP TO INSURED. | 45 | |
| 7288915044 | FL 60 A-C | POLICY ID NUMBER | 46 | |
| 7288916469 | FL 61 A-C | GROUP NAME | 47 | |
| 7288918419 | FL 62 A-C | GROUP NUMBER | 48 | |
| 7288920622 | FL 63 | AUTHORIZATION OR REFERRAL NUMBER | 49 | |
| 7288921732 | FL 64 | DOCUMENT CONTROL NUMBER. | 50 | |
| 7288923332 | FL 65 | EMPLOYER NAME. IF WC IS INVOLVED | 51 | |
| 7288934736 | FL 66 | DIAGNOSIS AND PROCEDURE CODE QUALIFIER | 52 | |
| 7288936938 | FL 67 | PRINCIPAL DIAGNOSIS | 53 | |
| 7288939056 | FL67 A-Q | OTHER DIAGNOSIS CODES | 54 | |
| 7288940808 | FL68 | RESERVED. NOT USED | 55 | |
| 7288942161 | FL69 | ADMITTING DIAGNOSIS. REQUIRED FOR INPATIENT | 56 | |
| 7288943808 | FL 70 A-C | REASON FOR VISIT - READ BOOK FORE MORE DETAILS | 57 | |
| 7288947230 | FL 71 | NOT USED. PROSPECTIVE PAYMENT SYSTEMS CODE | 58 | |
| 7288948482 | FL 72 | EXTERNAL CAUSE OF INJURY CODES. USUALLY NOT USED UNLESS PAYER REQUIRES | 59 | |
| 7288951435 | FL 73 | RESERVED. NOT USED | 60 | |
| 7288951436 | FL 74 | PRINCIPAL PROCEDURE CODE AND DATE. REQUIRED FOR INPATIENT | 61 | |
| 7288984402 | FL 75 | RESERVED. NOT USED | 62 | |
| 7288991001 | FL76 | ATTENDING PROVIDER NAME AND IDENTIFIERS INCLUDING NPI. IF NOT REQUIRED, DO NOT SEND. | 63 | |
| 7288994945 | SECONDARY IDENTIFIER QAULIFIERS | 0B STATE LICENSE 1G PROVIDER UPIN G2 PROVIDER COMMERCIAL NUMBER | 64 | |
| 7288997883 | FL77 | OPERATING PROVIDER AND IDENTIFIERS INCLUDING NPI, SAME AS ABOVE | 65 | |
| 7288999995 | FL 78-79 | OTHER PROVIDER NAMES - SAME AS ABOVE DN- REFERRING PROVIDER ZZ- OTHER OPERATING PHYSICIAN | 66 | |
| 7289005850 | FL 80 | REMARKS. SPECIAL ANNOTATIONS. REMARKS NEEDED TO PROVIDE INFO THAT IS NOT SHOWN ELSEWHERE ON THE BILL BUT IS NECESSARY FOR PROPER PAYMENT | 67 | |
| 7289010584 | FL 81 | USED TO REPORT ADDL CODES RELATED TO FL OR TO REPORT EXTERNAL CODE LIST | 68 |