PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM REPORTING MANUAL
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1 PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM REPORTING MANUAL Inpatient UB-04 Data Reporting April 2007 Revised: August 2015 ay Status Report for
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3 Table of Contents Overview... 1 Detail Record Quick Reference (Includes UB-04 Form Locator)... 2 Header Record Format... 6 Header Record Specifications... 7 Detail Record Format Detail Record Specifications Edits not Associated with Specific Fields Trailer Record Format Trailer Record Specifications Appendix A Format for Continuation Records Appendix B United States/Territory Abbreviations Appendix C Payer ID/Health Plan ID Numbers (NAIC Codes) Appendix D Country Abbreviations Market Street, Suite 400 Harrisburg, PA Phone: (717) Fax: (717)
4 Overview Background The (PHC4) is an independent state agency formed under Pennsylvania statute Act 89 of 1986, and amended by Act 3 of To help improve the quality and restrain the cost of health care, PHC4 promotes health care competition through the collection, analysis and public dissemination of uniform cost and quality-related information. Purpose of this Manual This manual is designed to assist facilities with their PHC4 Inpatient data submission. Listed below are some important points to remember: Data is submitted on a quarterly basis and is required 90 days from the close of each quarter. Data must be submitted using the secure portal at Data is required to be submitted in a fixed 3900 character record line length, with a carriage return-line feed after each record. Standard text characters with ASCII values between 32 and 127 are accepted. This range includes: o uppercase and lowercase letters o digits o standard punctuation found on a normal keyboard Characters not accepted: o ASCII values 31 or less (pagination characters such as but not limited to tabs or page breaks) o ASCII values 128 and higher (characters such as non-latin characters such as Greek or Cyrillic letters - α, β, æ, Ф, etc., and letters with accent marks such as tildes, umlauts, graves, etc. - ä, ô, é, ñ, etc.) Required s and Coding Guidelines: All inpatient discharges including psychiatric and/or behavioral health, rehabilitation, and drug and alcohol records are required. Skilled nursing facility (SNF), swing bed, transitional care unit, 23-hour observation, and hospice records are not required and should not be submitted. The Statement Covers Period Through (Field 6b) is in the submission quarter. Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 1
5 Detail Record Quick Reference Data Element Field Number/ UB-04 Form Locator Page Number Accident State Admission Hour Admission/Start of Care Date Admitting Diagnosis Code Assignment of Benefits Certification Indicator 53a-53c 103 Attending Provider - First Name 76e 142 Attending Provider - Last Name 76d 131 Attending Provider - NPI 76a 138 Attending Provider - Secondary Identifier 76c 140 Attending Provider - Secondary Identifier Qualifier 76b 139 Billing Provider City, State, Zip Code 1c1-1c3 37 Billing Provider Name 1a 35 Billing Provider Street Address 1b 36 Billing Provider Telephone, Fax, Country Code 1d1-1d3 38 Code-Code Field (Code Qualifier) 81a1-81d1 155 Code-Code Field (Code) 81a2-81d2 156 Code-Code Field (Number or Value) 81a3-81d3 157 Condition Codes Diagnosis and Code Qualifier Discharge Hour Document Control Number (DCN) 64a-64c 114 Employer Name (of the Insured) 65a-65c 115 Estimated Amount Due - Payer 55a-55c 105 External Cause of Injury (ECI) Code 72a-72c 128 External Cause of Injury (ECI) Code 72a1-72c1 130 Present on Admission (POA) Indicator Federal Tax Number 5b 47 Federal Tax Number (sub-id) 5a 46 HCPCS Codes (by Revenue Code) 44a-44v 89 Hospital-acquired Infection: Code 121d1a-121d10a 164 Hospital-acquired Infection: 121d1b-121d10b 165 Multidrug-resistant Organism (MDRO) Hospital-acquired Infection: ICD-9-CM Code or NHSN Operative Category 121d1c-121d10c 166 Hospital-acquired Infection: Location 121d1d-121d10d 167 Insured's Group Name 61a-61c 111 Insured's Group Number 62a-62c 112 Insured s Name 58a-58c 108 Insured's Unique Identifier 60a-60c 110 Medical/Health Record Number 3b 44 National Provider Identifier - Billing Provider Non-covered Charges (by Revenue Code) 48a-48v 94 Non-covered Charges (Total) 48w 95 Occurrence Codes 31a1-34b1 74 Occurrence Dates 31a2-34b2 75 Occurrence Span Codes 35a1-36b1 76 Occurrence Span Dates From 35a2-36b2 77 Occurrence Span Dates Through 35a3-36b3 78 Operating Physician - First Name 77e 147 Operating Physician - Last Name 77d 146 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 2
6 Detail Record Quick Reference Data Element Field Number/ UB-04 Form Locator Page Number Operating Physician - NPI 77a 143 Operating Physician - Secondary Identifier 77c 145 Operating Physician - Secondary Identifier Qualifier 77b 144 Other (Billing) Provider Identifier 57a-57c 107 Other Diagnosis Code 67a2-67q2 122 Present on Admission (POA) Indicator Other Diagnosis Codes 67a1-67q1 120 Other Codes 74a1-74e1 135 Other Dates 74a2-74e2 136 Other Provider - First Name 78f-79f 153 Other Provider - Last Name 78e-79e 152 Other Provider - NPI 78b-79b 149 Other Provider - Provider Type Qualifier 78a-79a 148 Other Provider - Secondary Identifier 78d-79d 151 Other Provider - Secondary Identifier Qualifier 78c-79c 150 Page Count 43w1 87 Patient Address 9a 54 Patient Birth Date Patient City 9b 55 Patient Control Number 3a 43 Patient Country 9e 58 Patient Discharge Status Patient Hispanic/Latino Origin or Descent 103a 159 Patient Identifier 8a 52 Patient Morbidity 121b 162 Patient Name 8b 53 Patient Race 103b 160 Patient Severity Upon Admission 121a 161 Patient Sex Patient State 9c 56 Patient Zip Code 9d 57 Patient's Reason for Visit 70a-70c 126 Patient's Relationship to Insured 59a-59c 109 Payer ID/Health Plan ID 51a-51c 100 Payer Type and Name 50a-50c 97 Pay-to Address 2b 40 Pay-to City, State, Zip Code 2c1-2c3 41 Pay-to Name 2a 39 Point of Origin for Admission or Visit Principal Diagnosis Code Principal Diagnosis Present on Admission (POA) Indicator Principal Code Principal Date Prior Payments - Payer 54a-54c 104 Priority (Type) of Admission or Visit Prospective Payment System (PPS) Code Release of Information Certification Indicator 52a-52c 102 Remarks Field Reserved Field 121e 168 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 3
7 Detail Record Quick Reference Data Element Field Number/ UB-04 Form Locator Page Number Reserved for Assignment by the NUBC 2d 42 Reserved for Assignment by the NUBC 7 51 Reserved for Assignment by the NUBC Reserved for Assignment by the NUBC 37a-37b 79 Reserved for Assignment by the NUBC 49a-49w 96 Reserved for Assignment by the NUBC Reserved for Assignment by the NUBC Reserved for Assignment by the NUBC 75a-75d 137 Responsible Party Name 38a 80 Responsible Party Address 38b 81 Revenue Code (number 23 only) 42w 86 Revenue Code (numbers 1 through 22) 42a-42v 84 Service Date (by Revenue Code) 45a-45v 90 Service Units (by Revenue Code) 46a-46v 91 Statement Covers Period - From 6a 48 Statement Covers Period - Through 6b 49 Total Charges 47w 93 Total Charges (by Revenue Code) 47a-47v 92 Total Number of Pages 43w2 88 Treatment Authorization Code 63a-63c 113 Type of Bill 4 45 Uniform Patient Identifier (Social Security Number) Unusual Occurrence 121c 163 Value Amounts 39a2-41d2 83 Value Codes 39a1-41d1 82 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 4
8 Header Record Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 5
9 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 6 Header Record Format Data Element Data Element From To Data Type Format 1 Data Source Identifier 1 15 X(15) Left justify. Blank fill right. 2 Data Source Name/Address X(100) Name = Position Address 1 = Position Address 2 = Position City = Position State = Position Zip Code = Position Period Covered First Day (6) MMDDYY 4 Period Covered Last Day (6) MMDDYY 5 Run Date (6) MMDDYY. Date file was created. 6 Inpatient/Outpatient Indicator X(1) I = Inpatient Claims O = Outpatient Claims 7 Batch/Job/Run Number X(25) For facility s use in identifying the file. 8 Filler X(3739) 9 Submission Type X(1) O = Original Submission R = Resubmission of Original Data 10 Record Type X(1) H = Header Record
10 Field 1 Record Location 1-15 Data Source Identifier The unique identification number assigned to the provider submitting the bill. Use your National Provider Identifier (NPI). 15 character field; Alphanumeric; Left-justified Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 7
11 Field 2 The name and address of the facility. Data Source Name and Address Name = Position Address 1 = Position Address 2 = Position City = Position State = Position Zip Code = Position character field; Alphanumeric; Left-justified Record Location Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 8
12 Field 3 Record Location Period Covered First Day The first day of the quarter from which the data is provided. Use the format MMDDYY without punctuation. 6 character field; Numeric Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 9
13 Field 4 Record Location Period Covered Last Day The last day of the quarter from which the data is provided. Use the format MMDDYY without punctuation. 6 character field; Numeric Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 10
14 Field 5 The date the file was produced. Run Date Use the format MMDDYY without punctuation. 6 character field; Numeric Record Location Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 11
15 Field 6 Record Location 134 Inpatient Indicator The letter indicating claims contained in this file are Inpatient. I = Inpatient 1 character field; Alphanumeric Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 12
16 Field 7 Record Location Batch/Job/Run Number The number for the facility s use in identifying the media. Fill with the number that will identify this media. 25 character field; Alphanumeric Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 13
17 Field 8 Record Location Reserved for future use by the Council. Blank fill character field; Alphanumeric Filler Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 14
18 Field 9 Record Location 3899 Submission Type The code indicating whether this submission is an original submission or a resubmission of original data. Coding Structure: O = Original Submission R = Resubmission of Original Media 1 character field; Alphanumeric Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 15
19 Field 10 Record Location 3900 Record Type The code indicating the record is a Header Record. H = Header Record 1 character field; Alphanumeric Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 16
20 Detail Record Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 17
21 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 18 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 1a Billing Provider Name 1 25 X(25) Left justify No 1b Billing Provider Street Address X(25) Left justify No 1c1 Billing Provider City X(12) Left justify No 1c2 Billing Provider State X(2) All positions filled No 1c3 Billing Provider Zip Code X(9) XXXXXYYYY. If the +4 extension is unknown, leave blank. No 1d1 Billing Provider Telephone X(10) Include area code, no dashes or parentheses No 1d2 Billing Provider Fax X(10) Include area code, no dashes or parentheses No 1d3 Billing Provider Country Code X(2) US = United States No 2a Pay-to Name X(25) Left justify No 2b Pay-to Address X(25) Left justify No 2c1 Pay-to City X(16) Left justify No 2c2 Pay-to State X(2) All positions filled No 2c3 Pay-to Zip Code X(5) XXXXX. Do not include the +4 extension. No 2d NUBC Reserved Field X(25) Blank fill No 3a Patient Control Number X(24) Left justify Yes 3b Medical/Health Record Number X(24) Left justify Yes 4 Type of Bill X(4) All positions filled No 5a Federal Tax Number (sub-id) X(4) All positions filled No 5b Federal Tax Number X(10) NN-NNNNNNN. Include Hyphen. Yes 6a Statement Covers Period - From (6) MMDDYY Yes 6b Statement Covers Period - Through (6) MMDDYY Yes 7 NUBC Reserved Field X(15) Blank fill No 8a Patient Identifier X(19) Left justify No 8b Patient Name X(29) Left justify Yes 9a Patient Address X(40) Left justify No 9b Patient City X(30) Left justify No 9c Patient State X(2) Left justify No 9d Patient Zip Code X(9) XXXXXYYYY. If the +4 extension is unknown, leave blank. Yes 9e Patient Country X(2) All positions filled Yes
22 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 19 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 10 Patient Birth Date (8) MMDDYYYY Yes 11 Patient Sex X(1) M = Male; F = Female; U = Unknown Yes 12 Admission/Start of Care Date (6) MMDDYY Yes 13 Admission Hour (2) All positions filled No 14 Priority (Type) of Admission or Visit X(1) All positions filled Yes 15 Point of Origin for Admission or Visit X(1) All positions filled Yes 16 Discharge Hour (2) All positions filled No 17 Patient Discharge Status X(2) All positions filled Yes 18 Condition Code X(2) All positions filled No 19 Condition Code X(2) All positions filled No 20 Condition Code X(2) All positions filled No 21 Condition Code X(2) All positions filled No 22 Condition Code X(2) All positions filled No 23 Condition Code X(2) All positions filled No 24 Condition Code X(2) All positions filled No 25 Condition Code X(2) All positions filled No 26 Condition Code X(2) All positions filled No 27 Condition Code X(2) All positions filled No 28 Condition Code X(2) All positions filled No 29 Accident State X(2) Blank fill if not accident-related. Otherwise use the state abbreviation. No 30 NUBC Reserved Field X(24) Blank fill No 31a1 Occurrence Code 31a X(2) Left justify No 31a2 Occurrence Date 31a (6) MMDDYY No 32a1 Occurrence Code 32a X(2) Left justify No 32a2 Occurrence Date 32a (6) MMDDYY No 33a1 Occurrence Code 33a X(2) Left justify No 33a2 Occurrence Date 33a (6) MMDDYY No 34a1 Occurrence Code 34a X(2) Left justify No 34a2 Occurrence Date 34a (6) MMDDYY No 31b1 Occurrence Code 31b X(2) Left justify No
23 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 20 Detail Record Format Data Element Data Element From To Data Type Format 31b2 Occurrence Date 31b (6) MMDDYY No 32b1 Occurrence Code 32b X(2) Left justify No 32b2 Occurrence Date 32b (6) MMDDYY No 33b1 Occurrence Code 33b X(2) Left justify No 33b2 Occurrence Date 33b (6) MMDDYY No 34b1 Occurrence Code 34b X(2) Left justify No 34b2 Occurrence Date 34b (6) MMDDYY No 35a1 Occurrence Span Code 35a X(2) Left justify No 35a2 Occurrence Span Date 35a (From) (6) MMDDYY No 35a3 Occurrence Span Date 35a (Through) (6) MMDDYY No 36a1 Occurrence Span Code 36a X(2) Left justify No 36a2 Occurrence Span Date 36a (From) (6) MMDDYY No 36a3 Occurrence Span Date 36a (Through) (6) MMDDYY No 35b1 Occurrence Span Code 35b X(2) Left justify No 35b2 Occurrence Span Date 35b (From) (6) MMDDYY No 35b3 Occurrence Span Date 35b (Through) (6) MMDDYY No 36b1 Occurrence Span Code 36b X(2) Left justify No 36b2 Occurrence Span Date 36b (From) (6) MMDDYY No 36b3 Occurrence Span Date 36b (Through) (6) MMDDYY No 37a NUBC Reserved Field X(8) Blank fill No 37b NUBC Reserved Field X(8) Blank fill No 38a Responsible Party Name X(40) Left justify No 38b Responsible Party Address X(160) Left justify No 39a1 Value Code 39a X(2) Left justify No 39a2 Value Amount 39a (10) Right justify No 40a1 Value Code 40a X(2) Left justify No 40a2 Value Amount 40a (10) Right justify No 41a1 Value Code 41a X(2) Left justify No 41a2 Value Amount 41a (10) Right justify No 39b1 Value Code 39b X(2) Left justify No Currently Edited
24 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 21 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 39b2 Value Amount 39b (10) Right justify No 40b1 Value Code 40b X(2) Left justify No 40b2 Value Amount 40b (10) Right justify No 41b1 Value Code 41b X(2) Left justify No 41b2 Value Amount 41b (10) Right justify No 39c1 Value Code 39c X(2) Left justify No 39c2 Value Amount 39c (10) Right justify No 40c1 Value Code 40c X(2) Left justify No 40c2 Value Amount 40c (10) Right justify No 41c1 Value Code 41c X(2) Left justify No 41c2 Value Amount 41c (10) Right justify No 39d1 Value Code 39d X(2) Left justify No 39d2 Value Amount 39d (10) Right justify No 40d1 Value Code 40d X(2) Left justify No 40d2 Value Amount 40d (10) Right justify No 41d1 Value Code 41d X(2) Left justify No 41d2 Value Amount 41d (10) Right justify No 42a Revenue Code X(4) All positions filled Yes 44a HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45a Service Date (6) Ambulatory/Outpatient Reporting Only No 46a Service Units (7) Right justify No 47a Total Charges (10) Right justify Yes 48a Non-covered Charges (10) Right justify No 49a NUBC Reserved Field X(2) Blank fill No 42b Revenue Code X(4) All positions filled Yes 44b HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45b Service Date (6) Ambulatory/Outpatient Reporting Only No 46b Service Units (7) Right justify No 47b Total Charges (10) Right justify Yes 48b Non-covered Charges (10) Right justify No
25 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 22 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 49b NUBC Reserved Field X(2) Blank fill No 42c Revenue Code X(4) All positions filled Yes 44c HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45c Service Date (6) Ambulatory/Outpatient Reporting Only No 46c Service Units (7) Right justify No 47c Total Charges (10) Right justify Yes 48c Non-covered Charges (10) Right justify No 49c NUBC Reserved Field X(2) Blank fill No 42d Revenue Code X(4) All positions filled Yes 44d HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45d Service Date (6) Ambulatory/Outpatient Reporting Only No 46d Service Units (7) Right justify No 47d Total Charges (10) Right justify Yes 48d Non-covered Charges (10) Right justify No 49d NUBC Reserved Field X(2) Blank fill No 42e Revenue Code X(4) All positions filled Yes 44e HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45e Service Date (6) Ambulatory/Outpatient Reporting Only No 46e Service Units (7) Right justify No 47e Total Charges (10) Right justify Yes 48e Non-covered Charges (10) Right justify No 49e NUBC Reserved Field X(2) Blank fill No 42f Revenue Code X(4) All positions filled Yes 44f HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45f Service Date (6) Ambulatory/Outpatient Reporting Only No 46f Service Units (7) Right justify No 47f Total Charges (10) Right justify Yes 48f Non-covered Charges (10) Right justify No 49f NUBC Reserved Field X(2) Blank fill No 42g Revenue Code X(4) All positions filled Yes
26 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 23 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 44g HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45g Service Date (6) Ambulatory/Outpatient Reporting Only No 46g Service Units (7) Right justify No 47g Total Charges (10) Right justify Yes 48g Non-covered Charges (10) Right justify No 49g NUBC Reserved Field X(2) Blank fill No 42h Revenue Code X(4) All positions filled Yes 44h HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45h Service Date (6) Ambulatory/Outpatient Reporting Only No 46h Service Units (7) Right justify No 47h Total Charges (10) Right justify Yes 48h Non-covered Charges (10) Right justify No 49h NUBC Reserved Field X(2) Blank fill No 42i Revenue Code X(4) All positions filled Yes 44i HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45i Service Date (6) Ambulatory/Outpatient Reporting Only No 46i Service Units (7) Right justify No 47i Total Charges (10) Right justify Yes 48i Non-covered Charges (10) Right justify No 49i NUBC Reserved Field X(2) Blank fill No 42j Revenue Code X(4) All positions filled Yes 44j HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45j Service Date (6) Ambulatory/Outpatient Reporting Only No 46j Service Units (7) Right justify No 47j Total Charges (10) Right justify Yes 48j Non-covered Charges (10) Right justify No 49j NUBC Reserved Field X(2) Blank fill No 42k Revenue Code X(4) All positions filled Yes 44k HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45k Service Date (6) Ambulatory/Outpatient Reporting Only No
27 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 24 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 46k Service Units (7) Right justify No 47k Total Charges (10) Right justify Yes 48k Non-covered Charges (10) Right justify No 49k NUBC Reserved Field X(2) Blank fill No 42l Revenue Code X(4) All positions filled Yes 44l HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45l Service Date (6) Ambulatory/Outpatient Reporting Only No 46l Service Units (7) Right justify No 47l Total Charges (10) Right justify Yes 48l Non-covered Charges (10) Right justify No 49l NUBC Reserved Field X(2) Blank fill No 42m Revenue Code X(4) All positions filled Yes 44m HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45m Service Date (6) Ambulatory/Outpatient Reporting Only No 46m Service Units (7) Right justify No 47m Total Charges (10) Right justify Yes 48m Non-covered Charges (10) Right justify No 49m NUBC Reserved Field X(2) Blank fill No 42n Revenue Code X(4) All positions filled Yes 44n HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45n Service Date (6) Ambulatory/Outpatient Reporting Only No 46n Service Units (7) Right justify No 47n Total Charges (10) Right justify Yes 48n Non-covered Charges (10) Right justify No 49n NUBC Reserved Field X(2) Blank fill No 42o Revenue Code X(4) All positions filled Yes 44o HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45o Service Date (6) Ambulatory/Outpatient Reporting Only No 46o Service Units (7) Right justify No 47o Total Charges (10) Right justify Yes
28 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 25 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 48o Non-covered Charges (10) Right justify No 49o NUBC Reserved Field X(2) Blank fill No 42p Revenue Code X(4) All positions filled Yes 44p HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45p Service Date (6) Ambulatory/Outpatient Reporting Only No 46p Service Units (7) Right justify No 47p Total Charges (10) Right justify Yes 48p Non-covered Charges (10) Right justify No 49p NUBC Reserved Field X(2) Blank fill No 42q Revenue Code X(4) All positions filled Yes 44q HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45q Service Date (6) Ambulatory/Outpatient Reporting Only No 46q Service Units (7) Right justify No 47q Total Charges (10) Right justify Yes 48q Non-covered Charges (10) Right justify No 49q NUBC Reserved Field X(2) Blank fill No 42r Revenue Code X(4) All positions filled Yes 44r HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45r Service Date (6) Ambulatory/Outpatient Reporting Only No 46r Service Units (7) Right justify No 47r Total Charges (10) Right justify Yes 48r Non-covered Charges (10) Right justify No 49r NUBC Reserved Field X(2) Blank fill No 42s Revenue Code X(4) All positions filled Yes 44s HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45s Service Date (6) Ambulatory/Outpatient Reporting Only No 46s Service Units (7) Right justify No 47s Total Charges (10) Right justify Yes 48s Non-covered Charges (10) Right justify No 49s NUBC Reserved Field X(2) Blank fill No
29 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 26 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 42t Revenue Code X(4) All positions filled Yes 44t HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45t Service Date (6) Ambulatory/Outpatient Reporting Only No 46t Service Units (7) Right justify No 47t Total Charges (10) Right justify Yes 48t Non-covered Charges (10) Right justify No 49t NUBC Reserved Field X(2) Blank fill No 42u Revenue Code X(4) All positions filled Yes 44u HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45u Service Date (6) Ambulatory/Outpatient Reporting Only No 46u Service Units (7) Right justify No 47u Total Charges (10) Right justify Yes 48u Non-covered Charges (10) Right justify No 49u NUBC Reserved Field X(2) Blank fill No 42v Revenue Code X(4) All positions filled Yes 44v HCPCS Code X(14) Ambulatory/Outpatient Reporting Only No 45v Service Date (6) Ambulatory/Outpatient Reporting Only No 46v Service Units (7) Right justify No 47v Total Charges (10) Right justify Yes 48v Non-covered Charges (10) Right justify No 49v NUBC Reserved Field X(2) Blank fill No 42w Revenue Code X(4) Enter 0001 for the total on the last record of the claim, or blank fill to indicate that further records Yes with additional service lines follow. 43w1 Page Count (3) Left justify Yes 43w2 Total Number of Pages (3) Left justify Yes 47w Total Charges (10) Right justify Yes 48w Non-covered Charges (10) Right justify No 49w NUBC Reserved Field X(2) Blank fill No 50a Payer Type and Name X(25) See manual for codes Yes 51a Payer ID/Health Plan ID X(15) Left justify Yes
30 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 27 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 52a Release of Information Certification Indicator X(1) Left justify No 53a Assignment of Benefits Certification Indicator X(1) Left justify No 54a Prior Payments - Payer (10) Right justify No 55a Estimated Amount Due - Payer (10) Left justify No 57a Other (Billing) Provider Identifier X(15) Left justify No 58a Insured's Name X(25) Left justify Yes 59a Patient's Relationship to Insured X(2) All positions filled Yes 60a Insured's Unique Identifier X(20) Left justify No 61a Insured's Group Name X(14) Left justify No 62a Insured's Group Number X(17) Left justify No 63a Treatment Authorization Code X(30) Left justify No 64a Document Control Number X(26) Left justify No 65a Employer Name (of the Insured) X(25) Left justify No 50b Payer Type and Name X(25) See manual for codes No 51b Payer ID/Health Plan ID X(15) Left justify No 52b Release of Information Certification Indicator X(1) Left justify No 53b Assignment of Benefits Certification Indicator X(1) Left justify No 54b Prior Payments - Payer (10) Right justify No 55b Estimated Amount Due - Payer (10) Left justify No 57b Other (Billing) Provider Identifier X(15) Left justify No 58b Insured's Name X(25) Left justify No 59b Patient's Relationship to Insured X(2) All positions filled No 60b Insured's Unique Identifier X(20) Left justify No 61b Insured's Group Name X(14) Left justify No 62b Insured's Group Number X(17) Left justify No 63b Treatment Authorization Code X(30) Left justify No 64b Document Control Number X(26) Left justify No
31 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 28 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 65b Employer Name (of the Insured) X(25) Left justify No 50c Payer Type and Name X(25) See manual for codes No 51c Payer ID/Health Plan ID X(15) Left justify No 52c Release of Information Certification Indicator X(1) Left justify No 53c Assignment of Benefits Certification Indicator X(1) Left justify No 54c Prior Payments - Payer (10) Right justify No 55c Estimated Amount Due - Payer (10) Left justify No 57c Other (Billing) Provider Identifier X(15) Left justify No 58c Insured's Name X(25) Left justify No 59c Patient's Relationship to Insured X(2) All positions filled No 60c Insured's Unique Identifier X(20) Left justify No 61c Insured's Group Name X(14) Left justify No 62c Insured's Group Number X(17) Left justify No 63c Treatment Authorization Code X(30) Left justify No 64c Document Control Number X(26) Left justify No 65c Employer Name (of the Insured) X(25) Left justify No 56 National Provider Identifier - Billing Provider X(15) Left justify No 66 Diagnosis and Code Qualifier X(1) All positions filled No 67-1 Principal Diagnosis Code X(7) Left justify Yes 67-2 Principal Diagnosis Code Present on Admission (POA) Indicator X(1) See manual for codes Yes 67a1 Other Diagnosis Code X(7) Left justify Yes 67a2 Other Diagnosis Code 1 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67b1 Other Diagnosis Code X(7) Left justify Yes 67b2 Other Diagnosis Code 2 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67c1 Other Diagnosis Code X(7) Left justify Yes
32 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 29 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 67c2 Other Diagnosis Code 3 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67d1 Other Diagnosis Code X(7) Left justify Yes 67d2 Other Diagnosis Code 4 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67e1 Other Diagnosis Code X(7) Left justify Yes 67e2 Other Diagnosis Code 5 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67f1 Other Diagnosis Code X(7) Left justify Yes 67f2 Other Diagnosis Code 6 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67g1 Other Diagnosis Code X(7) Left justify Yes 67g2 Other Diagnosis Code 7 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67h1 Other Diagnosis Code X(7) Left justify Yes 67h2 Other Diagnosis Code 8 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67i1 Other Diagnosis Code X(7) Left justify Yes 67i2 Other Diagnosis Code 9 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67j1 Other Diagnosis Code X(7) Left justify Yes 67j2 Other Diagnosis Code 10 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67k1 Other Diagnosis Code X(7) Left justify Yes 67k2 Other Diagnosis Code 11 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67l1 Other Diagnosis Code X(7) Left justify Yes 67l2 Other Diagnosis Code 12 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67m1 Other Diagnosis Code X(7) Left justify Yes 67m2 Other Diagnosis Code 13 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67n1 Other Diagnosis Code X(7) Left justify Yes
33 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 30 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 67n2 Other Diagnosis Code 14 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67o1 Other Diagnosis Code X(7) Left justify Yes 67o2 Other Diagnosis Code 15 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67p1 Other Diagnosis Code X(7) Left justify Yes 67p2 Other Diagnosis Code 16 Present on Admission (POA) Indicator X(1) See manual for codes Yes 67q1 Other Diagnosis Code X(7) Left justify Yes 67q2 Other Diagnosis Code 17 Present on Admission (POA) Indicator X(1) See manual for codes Yes 68 NUBC Reserved Field X(17) Blank fill No 69 Admitting Diagnosis Code X(7) Left justify Yes 70a Patient's Reason for Visit X(7) Ambulatory/Outpatient Reporting Only No 70b Patient's Reason for Visit X(7) Ambulatory/Outpatient Reporting Only No 70c Patient's Reason for Visit X(7) Ambulatory/Outpatient Reporting Only No 71 Prospective Payment System (PPS) Code X(4) Right justify Yes 72a External Cause of Injury (ECI) Code X(7) Left justify Yes 72a1 External Cause of Injury (ECI) Code 1 Present on Admission (POA) Indicator X(1) See manual for codes Yes 72b External Cause of Injury (ECI) Code X(7) Left justify Yes 72b1 External Cause of Injury (ECI) Code 2 Present on Admission (POA) Indicator X(1) See manual for codes Yes 72c External Cause of Injury (ECI) Code X(7) Left justify Yes 72c1 External Cause of Injury (ECI) Code 3 Present on Admission (POA) Indicator X(1) See manual for codes Yes 73 NUBC Reserved Field X(9) Blank fill No 74-1 Principal Code X(7) Left justify Yes 74-2 Principal Date (6) MMDDYY Yes 74a1 Other Code X(7) Left justify Yes 74a2 Other Date (6) MMDDYY Yes 74b1 Other Code X(7) Left justify Yes
34 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 31 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 74b2 Other Date (6) MMDDYY Yes 74c1 Other Code X(7) Left justify Yes 74c2 Other Date (6) MMDDYY Yes 74d1 Other Code X(7) Left justify Yes 74d2 Other Date (6) MMDDYY Yes 74e1 Other Code X(7) Left justify Yes 74e2 Other Date (6) MMDDYY Yes 75a NUBC Reserved Field X(4) Blank fill No 75b NUBC Reserved Field X(4) Blank fill No 75c NUBC Reserved Field X(4) Blank fill No 75d NUBC Reserved Field X(4) Blank fill No 76a Attending Provider - NPI X(11) Left justify No 76b Attending Provider - Secondary Identifier Qualifier X(2) "0B" is the only valid entry for this field. No 76c Attending Provider - Secondary Identifier X(9) Left justify Yes 76d Attending Provider - Last Name X(16) Left justify No 76e Attending Provider - First Name X(12) Left justify No 77a Operating Physician - NPI X(11) Left justify No 77b Operating Physician - Secondary Identifier Qualifier X(2) "0B" is the only valid entry for this field. No 77c Operating Physician - Secondary Identifier X(9) Left justify Yes 77d Operating Physician - Last Name X(16) Left justify No 77e Operating Physician - First Name X(12) Left justify No 78a Other Provider 1 - Provider Type Qualifier X(2) See manual for codes No 78b Other Provider 1 - NPI X(11) Left justify No 78c Other Provider 1 - Secondary Identifier Qualifier X(2) "0B" is the only valid entry for this field. No 78d Other Provider 1 - Secondary Identifier X(9) Left justify No 78e Other Provider 1 - Last Name X(16) Left justify No 78f Other Provider 1 - First Name X(12) Left justify No 79a Other Provider 2 - Provider Type Qualifier X(2) See manual for codes No
35 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 32 Detail Record Format Data Element Data Element From To Data Type Format Currently Edited 79b Other Provider 2 NPI X(11) Left justify No 79c Other Provider 2 - Secondary Identifier Qualifier X(2) "0B" is the only valid entry for this field. No 79d Other Provider 2 - Secondary Identifier X(9) Left justify No 79e Other Provider 2 - Last Name X(16) Left justify No 79f Other Provider 2 - First Name X(12) Left justify No 80 Remarks X(91) Left justify No 81a1 Code-Code Field (Code Qualifier) X(2) Left justify No 81a2 Code-Code Field (Code) X(10) Left justify No 81a3 Code-Code Field (Number or Value) (12) Right justify No 81b1 Code-Code Field (Code Qualifier) X(2) Left justify No 81b2 Code-Code Field (Code) X(10) Left justify No 81b3 Code-Code Field (Number or Value) (12) Right justify No 81c1 Code-Code Field (Code Qualifier) X(2) Left justify No 81c2 Code-Code Field (Code) X(10) Left justify No 81c3 Code-Code Field (Number or Value) (12) Right justify No 81d1 Code-Code Field (Code Qualifier) X(2) Left justify No 81d2 Code-Code Field (Code) X(10) Left justify No 81d3 Code-Code Field (Number or Value) (12) Right justify No 101 Uniform Patient Identifier (Social Security Number) X(9) Left justify Yes 103a Patient Hispanic/Latino Origin or Descent X(1) All positions filled Yes 103b Patient Race X(1) All positions filled Yes 121a Patient Severity Upon Admission X(1) Blank fill No 121b Patient Morbidity X(1) Blank fill No 121c Unusual Occurrence X(2) Blank fill No 121d1a Hospital-acquired Infection 1: Code X(2) Blank fill No Hospital-acquired Infection 1: 121d1b Multidrug-resistant Organism (MDRO) X(1) Blank fill No Hospital-acquired Infection 1: 121d1c Code or NHSN Operative Category X(7) Blank fill No
36 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 33 Detail Record Format Data Element Data Element From To Data Type Format Hospital-acquired Infection 1: 121d1d Location X(1) Blank fill No 121d2a Hospital-acquired Infection 2: Code X(2) Blank fill No Hospital-acquired Infection 2: 121d2b Multidrug-resistant Organism (MDRO) X(1) Blank fill No Hospital-acquired Infection 2: 121d2c Code or NHSN Operative Category X(7) Blank fill No Hospital-acquired Infection 2: 121d2d Location X(1) Blank fill No 121d3a Hospital-acquired Infection 3: Code X(2) Blank fill No Hospital-acquired Infection 3: 121d3b Multidrug-resistant Organism (MDRO) X(1) Blank fill No Hospital-acquired Infection 3: 121d3c Code or NHSN Operative Category X(7) Blank fill No Hospital-acquired Infection 3: 121d3d Location X(1) Blank fill No 121d4a Hospital-acquired Infection 4: Code X(2) Blank fill No Hospital-acquired Infection 4: 121d4b Multidrug-resistant Organism (MDRO) X(1) Blank fill No Hospital-acquired Infection 4: 121d4c Code or NHSN Operative Category X(7) Blank fill No Hospital-acquired Infection 4: 121d4d Location X(1) Blank fill No 121d5a Hospital-acquired Infection 5: Code X(2) Blank fill No Hospital-acquired Infection 5: 121d5b Multidrug-resistant Organism (MDRO) X(1) Blank fill No Hospital-acquired Infection 5: 121d5c Code or NHSN Operative Category X(7) Blank fill No Hospital-acquired Infection 5: 121d5d Location X(1) Blank fill No 121d6a Hospital-acquired Infection 6: Code X(2) Blank fill No Hospital-acquired Infection 6: 121d6b Multidrug-resistant Organism (MDRO) X(1) Blank fill No Hospital-acquired Infection 6: 121d6c Code or NHSN Operative Category X(7) Blank fill No Currently Edited
37 Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 34 Detail Record Format Data Element Data Element From To Data Type Format Hospital-acquired Infection 6: 121d6d Location X(1) Blank fill No 121d7a Hospital-acquired Infection 7: Code X(2) Blank fill No Hospital-acquired Infection 7: 121d7b Multidrug-resistant Organism (MDRO) X(1) Blank fill No Hospital-acquired Infection 7: 121d7c Code or NHSN Operative Category X(7) Blank fill No Hospital-acquired Infection 7: 121d7d Location X(1) Blank fill No 121d8a Hospital-acquired Infection 8: Code X(2) Blank fill No Hospital-acquired Infection 8: 121d8b Multidrug-resistant Organism (MDRO) X(1) Blank fill No Hospital-acquired Infection 8: 121d8c Code or NHSN Operative Category X(7) Blank fill No Hospital-acquired Infection 8: 121d8d Location X(1) Blank fill No 121d9a Hospital-acquired Infection 9: Code X(2) Blank fill No Hospital-acquired Infection 9: 121d9b Multidrug-resistant Organism (MDRO) X(1) Blank fill No Hospital-acquired Infection 9: 121d9c Code or NHSN Operative Category X(7) Blank fill No Hospital-acquired Infection 9: 121d9d Location X(1) Blank fill No 121d10a Hospital-acquired Infection 10: Code X(2) Blank fill No Hospital-acquired Infection 10: 121d10b Multidrug-resistant Organism (MDRO) X(1) Blank fill No Hospital-acquired Infection 10: 121d10c Code or NHSN Operative Category X(7) Blank fill No Hospital-acquired Infection 10: 121d10d Location X(1) Blank fill No 121e Reserved Field X(174) Blank fill No Currently Edited
38 Field 1a Billing Provider Name The name of the provider submitting the bill. 25 character field; Alphanumeric; Left-justified Record Location 1-25 NUBC Reference UB-04, Form Locator 01 (Line 1) Note This field is currently not edited. Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 35
39 Field 1b Record Location Billing Provider Street Address The street address of the provider submitting the bill. The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-to Address Field. 25 character field; Alphanumeric; Left-justified NUBC Reference UB-04, Form Locator 01 (Line 2) Note This field is currently not edited. Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 36
40 Field 1c1-1c3 Billing Provider City, State, Zip Code The city, state, and zip code of the provider submitting the bill. For a list of State/Territory abbreviations, see Appendix B. 23 character field; Alphanumeric; Left-justified Record Location 1c1- Billing Provider City: c2- Billing Provider State: c3- Billing Provider Zip Code: NUBC Reference UB-04, Form Locator 01 (Line 3) Note This field is currently not edited. Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 37
41 Field 1d1-1d3 Billing Provider Telephone, Fax, Country Code The telephone, fax, and country code of the provider submitting the bill. Country Code is required if other than US (United States). See Appendix D for the full list. 22 character field; Alphanumeric; Left-justified Record Location 1d1- Billing Provider Telephone: d2- Billing Provider Fax: d3- Billing Provider Country Code: NUBC Reference UB-04, Form Locator 01 (Line 4) Note This field is currently not edited. Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 38
42 Field 2a Record Location Pay-to Name The Pay-to Name that the provider submitting the bill intends payment to be sent if different than the Billing Provider Name. 25 character field; Alphanumeric; Left-justified NUBC Reference UB-04, Form Locator 02 (Line 1) Note This field is currently not edited. Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 39
43 Field 2b Record Location Pay-to Address The Pay-to address that the provider submitting the bill intends payment to be sent if different than the Billing Provider Address. Address may include post office box or street name and number. 25 character field; Alphanumeric; Left-justified NUBC Reference UB-04, Form Locator 02 (Line 2) Note This field is currently not edited. Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 40
44 Field 2c1-2c3 Pay-to City, State, Zip Code The Pay-to city, state, and zip code that the provider submitting the bill intends payment to be sent if different than the Billing Provider City, State and Zip Code. For a list of State/Territory abbreviations, see Appendix B. 23 character field; Alphanumeric; Left-justified Record Location 2c1- Pay-to City: c2- Pay-to State: c3- Pay-to Zip Code: NUBC Reference UB-04, Form Locator 02 (Line 3) Note This field is currently not edited. Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 41
45 Field 2d Reserved for Assignment by the NUBC Reserved for Assignment by the NUBC. Blank fill. 25 character field; Alphanumeric Record Location NUBC Reference UB-04, Form Locator 02 (Line 4) Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 42
46 Field 3a Revised May 2011 Record Location NUBC Reference Purpose Revised May 2011 Error Code: 003a Patient Control Number Patient s unique (alphanumeric) number assigned by the provider to facilitate retrieval of the individual s account of services (accounts receivable) containing the financial billing records and any postings of payment. Use the patient s account billing number. 24 character field; Alphanumeric; Left-justified UB-04, Form Locator 03a To identify the claim and perform matches with other data sources. Field Edit Criteria: Error Report Message: Patient Control Number Invalid Reason: The Control Number is either all zeros or all spaces. User Response: Enter the correct Patient Control Number. Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 43
47 Field 3b Revised May 2011 Record Location NUBC Reference Purpose Revised May 2011 Error Code: 003b Medical/Health Record Number The number assigned to the patient s medical/health record by the provider. The medical/health record number references a file that contains the history of treatment. It should not be substituted for the Patient Control Number (field 3a), which is assigned by the provider to facilitate retrieval of the individual financial record, which is typically associated with an episode of care. 24 character field; Alphanumeric; Left-justified UB-04, Form Locator 03b To identify the claim and perform matches with other data sources. Field Edit Criteria: Error Report Message: Medical/Health Record Number Invalid Reason: The Medical/Health Record Number is either all zeros or all spaces. User Response: Enter the correct Medical/Health Record Number. Pennsylvania Uniform Billing Form Reporting Manual for Inpatient Facilities 44
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