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Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

Required/Optional

Remarks

1	Billing Provider Information		Required		Four-lines of information:
					Name
	NOTE: This is the physical				Address
	address of the location where				City/State/Zip
	services were provided. This is				Phone: 123-123-1234
	not a Post Office Box address.
2	Pay-To Provider Information		Situational		Required if the pay-to
					provider address is different
	NOTE: A PO Box is acceptable				than the billing provider.
	in this space.
3a	Patient Control Number		Optional		Enter your patient account
					number, if provided this
					number will be returned on
					the EOB/EOP.
3b	Medical/Health Record Number		Optional		May be used for the patient’s
					medical record number. This
					field is not reported back on
					the EOB/EOP.
4	Bill Type		Required		Use NUBC taxonomy tables
					for acceptable values
					NOTE: This field plays a role
					in the adjudication of the
					claim. An incorrect value in
					this field could result in an
					incorrect payment.
5	Federal Tax ID		Required		Enter number WITHOUT
					hyphen: NNNNNNNNN
					NOTE: Forms are scanned
					into electronic files; a hyphen
					may result in payment
					inaccuracy or rejection of
					your claim.
6	Statement Covers From and		Required		Outpatient = enter the first
	Thru Dates				and last dates of services
					billed on this claim.
	FORMAT: MMDDYY without				Inpatient = enter admit and
	dashes, slashes or spaces.				discharge date for this
					admission. If interim billing
					is being performed, enter the
					first and last dates of the
					services that are being billed
					on the form.
7	Unassigned		Not Used
8a	Patient ID#		Required		Enter patient’s DCHP ID#:
					STAR: 9 numeric characters
					CHIP: 9 alpha-numeric
					characters with alpha
Page 1 of 9				Version 1.1 dated 5-27-07
Required = Mandatory		Optional = used at discretion of provider
Preferred = if available, please provide		Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

Required/Optional

Remarks

					character appearing in the lead
					position.
8b	Patient Name		Required		Patient name:
					Last, First Middle
					Sample: SMITH, MARY JO
9a	Patient Address		Required		Patient’s street address
9b	Patient City		Required		Patient’s city
9c	Patient State		Required		Patient’s state – 2-digit USPO
					abbreviation required
9d	Patient Zip Code		Required		Patient’s zip code – 5 digits
					are required. 9-digit is
					optional. If 9-digit is used
					DO NOT use a hyphen.
9e	Patient County Code		Optional		If used, must use codes
					provided by American
					National Standards Institute in
					ISO3166
10	Date of Birth		Required		Enter date: MMDDYYYY
					without hyphens, slashes or
					spaces
11	Sex		Required		M = male
					F = female
					U = unknown
12	Admission or Start of Care Date		Required on both inpatient		Enter date: MMDDYY
			and outpatient claims		without hyphens, slashes or
					spaces
13	Admission Hour		Required		Use NUBC taxonomy tables
					for acceptable values: 00
					through 23 to define the hour
14	Admission Type		Required on Inpatient		1 = emergency
					2 = urgent
			Optional on Outpatient		3 = elective
					4 = newborn
					5 = trauma
					9 = information not available
15	Admission Source		Required		Use NUBC taxonomy tables
					for acceptable values
16	Discharge Hour		Required on inpatient		Use NUBC taxonomy tables
			where bill type end is a 1,		for acceptable values: 00
			2, 3, or 4.		through 23 to define the hour
			Optional on outpatient
17	Discharge Status		Required on inpatient		Use NUBC taxonomy tables
					for acceptable values
			Not Used on outpatient
18-28	Condition Codes		Situational, but required		Use NUBC taxonomy tables
			where the condition code		for acceptable values
Page 2 of 9				Version 1.1 dated 5-27-07
Required = Mandatory		Optional = used at discretion of provider
Preferred = if available, please provide		Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field	Description		Required/Optional	Remarks

			applies to the bill
29	Accident State		Situational, but required	Use the 2-digit STATE
			where applicable. Always	abbreviation to designate the
			required when E-level	State in which the accident
			ICD9 codes are used.	occurred.
30	Unassigned		Not Used
31 a & b	Occurrence Code and Date		Situational, but required	Use NUBC taxonomy tables
through			where the occurrence code	for acceptable values
34 a & b			applies to the bill
35 a & b	Occurrence Span Code and		Situational, but required	Use NUBC taxonomy tables
through	Dates		where the occurrence code	for acceptable values
36 a & b			and span dates apply to the
			bill
37	Unassigned		Not Used
38	Responsible Party Name and		Not Used	Providers may complete this
	Address			field, but it will not be used
				for claims processing and this
				information will not be
				reported back.
				If used:
				Name
				Address
				City/State/Zip
				If a 9-digit zip is used, it must
				be formatted as nnnnn-nnnn
				with hyphen displayed.
39a,b,c,d	Value Codes and Amounts		Situational, but required	Use NUBC taxonomy tables
through			where the occurrence code	for acceptable values
41a,b,c,d			and span dates apply to the
			bill
42	Revenue Code		Required on both inpatient	Use NUBC taxonomy tables
			and outpatient claims	for acceptable values
43	Description		Required on paper claims	Use the Standard
				Abbreviation as determined
				by NUBC UB04
				specifications
44	HCPCS Code or Rate		REQUIRED as shown to	Inpatient:
			the right	Rev Codes 0100 through 0219
				and the 100X series must
				show the unit room rate.
				Outpatient:
				Revenue Codes 0450 through
				0459 must be HCPCS coded
				with the applicable level of
				care describing the visit.
				99281 – Level 1
				99282 – Level 2
Page 3 of 9			Version 1.1 dated 5-27-07
Required = Mandatory		Optional = used at discretion of provider
Preferred = if available, please provide		Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field	Description	Required/Optional	Remarks

			99283 – Level 3
			99284 – Level 4
			99285 – Level 5
			See Appendix A below for a
			list of all UB Rev Codes that
			must be HCPCS-coded on the
			Outpatient UB04 form.
45	Service Date	Inpatient: Do not Use	MMDDYY
		Outpatient: Required
46	Service Units	REQUIRED as shown to	Inpatient:
		the right	Rev Codes 0100 through 0219
			and the 100X series must
			show the number of days
			billed for each
			accommodation.
			Outpatient:
			UB Rev Code 0762 requires
			number of hours not to exceed
			23. Other codes may be
			populated at provider’s
			discretion.
47	Total Charges	Required
48	Non-Covered Charges	Situational, this	Inpatient Claims: The charges
		information is required if	represented in field 47 that
		some of the charges	fall on dates of service that
		shown in field 47 are not	were denied by utilization
		covered or if some dates	management, must be
		of services reflected in the	reflected in this column.
		charges in field 47 have
		been denied by DCHP
		utilization management.
49	Unassigned	Not Used
50	Payer Name	Required	Use multiple lines (a,b,c) if
			there is more than one payer.
			DCHP will always be the
			payer of last resort. Providers
			must bill other insurance and
			reflect the payment and denial
			on the bill send to DCHP.
51	Health Plan ID	Not required for STAR or	NOTE: This field may
		CHIP claims	become mandatory once
			health plans are assigned their
			own National Plan Identifier.
52	Release of Information	Required	Y = Yes
			N = No
53	Benefits Assigned	Required	Y = Yes

Page 4 of 9	Version 1.1 dated 5-27-07
Required = Mandatory	Optional = used at discretion of provider
Preferred = if available, please provide	Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

Required/Optional

Remarks

					All CHIP and STAR claims
					must indicate YES.
54	Prior Payments		Situational		Enter any dollar amount paid
					by the payer on this claim
55	Estimated Amount Due		Not Required
56	NPI		Required		The 10-digit NPI number of
					the BILLING PROVIDER
					identified in field 1 on the
					UB04
57	Other Billing Provider		Not Required
58	Insured Name		Required		Name of the insured person
					for the insurance shown in
					field 50.
					For STAR and CHIP this will
					always be the PATIENT.
59	Insured Relationship to Patient		Required		Use NUBC taxonomy tables
					for acceptable values
					For STAR and CHIP this will
					always = 18
60	Insured’s Unique ID		Required		Insurance ID# assigned by the
					health plan of payer to the
					insured person
					CHIP: 9-character numbers
					starting with a alpha character
					and followed by 8 numeric
					characters
					STAR: 9-numeric characters
61	Group Name		Required for other		Enter the name of group,
			insurance		which is will usually be the
					employer through which the
			Not Required for STAR		insurance is received.
			and CHIP
					For STAR and CHIP, this
					field can be left blank or can
					be populated with “DCHP”.
62	Insurance Group Number		Required for other		Enter the group ID# assigned
			insurance		by the applicable payer.
			Not Required for STAR		For STAR and CHIP this field
			and CHIP		can be left blank.
63	Treatment Authorization Codes		Situational		If prior authorization code
					was given for the services
					represented in the claim, enter
					than number in this space.
64	Document Control Number		Situational		If re-submitting a claim that
					was previously adjudicated,
Page 5 of 9				Version 1.1 dated 5-27-07
Required = Mandatory		Optional = used at discretion of provider
Preferred = if available, please provide		Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field	Description		Required/Optional		Remarks

			Required only for a claim		enter the Internal Control
			re-submission		Number shown on the DCHP
					Explanation of Payment
					(EOP) form.
65	Employer Name		Required for other		Enter the name of the
			insurance		employer who provides the
					insurance to the person shown
			Not Required for STAR		in field 58
			and CHIP
66	Diagnosis Code Qualifier		Required		Should always = 9 to indicate
					ICD9 code.
For all codes entered in field 67 through 74 decimals are assumed and should not be stated.
67	Principal or Present on		Required		Inpatient: Enter the principal
	Admission Code				diagnosis as defined by CMS
					Outpatient: Enter the
					diagnosis code that describes
					the reason for the visit
67 A-Q	Other Diagnosis Codes		Situational		Enter all other final diagnosis
					codes applicable to the visit or
					addressed in the visit or that
					explain why the services
					being billed were performed.
69	Admit Diagnosis		Inpatient: Required		Enter the applicable ICD9
					codes representing the reason
			Outpatient: Not Required		for admission
70	Patient’s Reason for Visit		Inpatient: Not Used		Enter the applicable ICD9
					codes.
			Outpatient: Required for
			Emergency Room, not
			required otherwise
71	PPS Code		REQUIRED for DRG-		Enter the applicable DRG
			based hospitals, otherwise		code determined by the
			this field in not required.		provider that applies to this
					claim.
72	External Cause of Injury Code		Situational		Enter the applicable E-level
					ICD9 code if the treatment
					was related to an accident
73	Unassigned		Not Used
74	Principal Procedure		Situational		Input the ICD9 surgical
					procedure code and the date
					of the surgery applicable to
					the treatment represented on
					the claim
74 a-e	Other Procedure		Situational		Input the ICD9 surgical
					procedure code and the date
					of the surgery applicable to
					the treatment represented on
					the claim
75	Unassigned		Not Used
Page 6 of 9				Version 1.1 dated 5-27-07
Required = Mandatory		Optional = used at discretion of provider
Preferred = if available, please provide		Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field	Description		Required/Optional	Remarks

76	Attending Provider Name and		Required	NPI
	Identifiers			Attending provider’s NPI
				number
	NOTE: There are 4 distinct
	fields within this box. Each			QUAL
	field must be completed as			Enter the qualifier of 1D
	shown in the far right column.			followed by Attending
				Provider’s TPI #
				LAST
				Last name of Attending
				Provider
				FIRST
				First name of Attending
				Provider
77	Operating Provider Name and		Situational	NPI
	Identifiers			Operating provider’s NPI
				number
	NOTE: There are 4 distinct
	fields within this box. Each			QUAL
	field must be completed, if			Enter the qualifier of 1D
	applicable, as shown in the far			followed by Operating
	right column.			Provider’s TPI #
				LAST
				Last name of Operating
				Provider
				FIRST
				First name of Operating
				Provider
78	Other Provider Name and		Situational – if applicable	NPI
	Identifiers		use this field for	Referring provider’s NPI
			REFERRING PROVIDER	number
	NOTE: There are 4 distinct
	fields within this box. Each			QUAL
	field must be completed, if			Enter the qualifier of 1D
	applicable, as shown in the far			followed by Referring
	right column.			Provider’s TPI #
				LAST
				Last name of Referring
				Provider
				FIRST
				First name of Referring
				Provider
79	Other Provider Name and		Situational	NPI
	Identifiers			Other provider’s NPI number
Page 7 of 9			Version 1.1 dated 5-27-07
Required = Mandatory		Optional = used at discretion of provider
Preferred = if available, please provide		Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field	Description	Required/Optional	Remarks

	NOTE: There are 4 distinct		QUAL
	fields within this box. Each		Enter the qualifier of 1D
	field must be completed. If		followed by Other Provider’s
	applicable, as shown in the far		TPI #
	right column.
			LAST
			Last name of Other Provider
			FIRST
			First name of Other Provider
80	Remarks Field	Situational	Used when in the judgment of
			the provider, the information
			is needed to substantiate the
			medical treatment and it is not
			supported elsewhere within
			the claim data set.
81	Code-Code Field	Situational	Used in accordance with the
			NUBC taxonomy set forth in
			the NUBC UB04
			specifications manual and
			published by the American
			Hospital Association.

Change Log:

Date	Version	Changes
5-17-07jc	1.0	Initial DRAFT version, posted on website but also used internally to vet
		requirements.
5-27-07jc	1.1	Updated as discussed internally. Most critical changes were to the
		following fields 44 and 46. In addition, Appendix A was added at the end
		of this document.

Page 8 of 9	Version 1.1 dated 5-27-07
Required = Mandatory	Optional = used at discretion of provider
Preferred = if available, please provide	Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

Required/Optional

Remarks

APPENDIX A: UB Rev Code That Required HCPCS Coding for all Outpatient Bill Types

(Revenue Codes not applicable to an outpatient claim or that do not require HCPCS coding on an outpatient claims are

omitted from the following list)

Disclaimer: Inclusion in the following does not imply that the Revenue Code is a covered service.

Please refer to applicable Medicaid regulations and to the UB04 Manual published by the American

Hospital Association for details.

CODES	CODES	CODES	CODES	CODES	CODES
029X	035X	045X	056X	077X	098X
030X	040X	046X	057X	090X	210X
031X	041X	047X	061X	091X
032X	042X	048X	073X	092X
033X	043X	054X	074X	096X
034X	044X	055X	075X	097X

All providers that use the UB04 form are strongly encouraged to subscribe the UB04 Manual published by the American Hospital Association. To the fullest extent possible, Driscoll Children’s Health Plan uses these specifications in processing claims.

Page 9 of 9	Version 1.1 dated 5-27-07
Required = Mandatory	Optional = used at discretion of provider
Preferred = if available, please provide	Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Question	Answer
Form Name	Ub 94 Form
Form Length	9 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 15 sec
Other names	ICD9, HCPCS, NPI, ub 94

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