UHIN STANDARDS COMMITTEE Standard/Specification UB04 FORM LOCATOR ELEMENTS Version 3

Transcription

1 UHIN STNDRDS OMMITTEE Standard/Specification U04 FORM LOTOR ELEMENTS Version 3 Purpose: The purpose of Standard/Specification U04 Form Locator Elements, is to clearly describe the use of each form locator in the U04 (MS1450) claim billing form and its crosswalk to the HIP X2232 Institutional implementation guide. The purpose of standardizing the use of the U04 is to create a more uniform electronic claim environment. UHIN Standard U04 Form Locator Elements, is compatible with all HIP requirements. It creates a uniform billing method for institutional claims. pplicability: ll institutional claims and encounters. For Property and asualty claims please refer to the Property and asualty / Worker s ompensation Standard U04 Form Locator elements. asic oncepts: Form Locator use is derived to the greatest degree possible from the Utah Uniform illing Instruction Manual 1 for the U04 facility claim form. crosswalk from the form locators to the S X Implementation Guide 2 is listed showing loop and segment/element (e.g., 2010 NM104 means Loop 2010, segment NM1, element 04). To the greatest degree possible, all generally required information to submit an electronic HIP compliant institutional claim is contained in this crosswalk. However, there will be instances where additional data is required to create a HIP-compliant transaction. Translator vendors must determine how to obtain any additional required data from provider billing or clinical systems. Detail: 1. Explanations of the use of each form locator are given in the U04 manual. 2. Explanations regarding the use of the S X12 data elements are given in the S X X2232 implementation guide. 3. If a ox is marked Not cross walked this means that this data element is not carried in the implementation guide. 4. n ** indicates that this requirement is unique to Utah. None of the Utah requirements contradicts the HIP use of the implementation guide. Utah-specific requirements are kept to a minimum. 5. ll Form Locators required by the implementation guide, are marked REQUIRED. Everything else is used under the conditions described in the implementation guide. Providers are responsible for knowing when certain Situational data elements are required in the implementation guide. 6. ll data edits on electronic data will conform to the edits outlined in the HIP implementation guide. Use of Paper Form: See the U04 manual for a detailed review of how each form locator is used. Implementation Issues: 1. This Standard shall be implemented with the implementation of the HIP 5010 Institutional implementation guide. 2. The HIP 837 transactions shall be implemented in conjunction with a 999 Functional cknowledgement and a 277 laim cknowledgement transaction. Payer Implementation Issues: Provider Implementation Issues 1. Due to Optical haracter Recognition system parameters, it is preferred that the U04 (MS1450) form that is printed in red be used by the provider 1 Utah Uniform illing Instruction Manual, Utah Hospital ssociation, pril 16, vailable at the Washington Publishing ompany web site, Page 1 of 18

2 Form Locator Table: Form Locator 1. Form Locator 2. Form Locator 3a. Form Locator 3b Form Locator 4. Form Locator 5. Form Locator 6. Form Locator 7. Form Locator 8a. Form Locator 8b. Form Locator 9a. Form Locator 9b. Form Locator 9c. Form Locator 9d. Form Locator 9e. Form Locator 10. Form Locator 11. Form Locator 12. Form Locator 13. Form Locator 14. Form Locator 15. Form Locator 16. Form Locator 17. Form Locator Form Locator 29. Form Locator 30. Form Locator Form Locator Form Locator 37. Provider Name, ddress and Telephone Number Pay-To ddress Patient ontrol Number (unique claim number) Medical/Health Record Number Type of ill Federal Tax Number Statement overs Period.(MMDDYY) Patient name. Last, First and Middle Initial. Use a comma as the indicator to separate the last, first and middle initial. No space should be left between a prefix and a name such as Maceth, VonSchmidt, and McEnroe. Patient Identifier Patient ddress. ity State Zip ountry code Patient irth Date. (MMDDYYYY) Patient Sex. dmission/start of are Date (MMDDYY) dmission Hour Priority (Type) of Visit Source of Referral for dmission or Visit Discharge Hour Patient Discharge Status ondition odes ccident State Occurrence ode and Date. Occurrence Span ode and Dates. Page 2 of 18

3 Form Locator 38. Form Locator Form Locator 42. Form Locator 43. Form Locator 43. Form Locator 44. Form Locator 45. Form Locator 45. Form Locator 46. Form Locator 47. Form Locator 48. Form Locator 49. Form Locator 50 a-c. Form Locator 51a-c. Form Locator 52a-c. Responsible Party Name and ddress. Value odes and mounts. Revenue odes. Must be valid U04 codes Revenue Description Page_ of_ HPS/Rates/HIPPS ode Service Date reation date Service Units Total harges (This cannot be a negative number.) Non overed charges (This cannot be a negative number.) Payer Name Health Plan ID Number Release of Information ertification Indicator Form Locator 53a-c. ssignment of enefits ertification indicator ( Y, N or W ) Form Locator 54 a-c. Form Locator 55 a-c. Form Locator 56. Form Locator 57 a-c. Form Locator 58 a-c. Form Locator 59 a-c. Form Locator 60 a-c. Form Locator 61 a-c. Form Locator 62 a-c. Form Locator 63 a-c. Form Locator 64 a-c. Form Locator 65a-c. Form Locator 66. Form Locator 67. Form Locator 67a-q. Form Locator 68. Prior Payments (Other Payer mounts) Estimated mount Due (Payer) National Provider Identifier - illing Provider Other (illing) Provider ID (Secondary Provider Numbers used to identify the provider per payer) Insured s Name Patients Relationship to the Insured Insured s Unique ID Insured s Group Name Insured s Group Number Treatment uthorization ode. This is not a required field. However, it is recommended that this information is sent if appropriate to the claim. Document ontrol Number.(Payers Original laim Number) Employer Name (of the Insured) Diagnosis and Procedure ode Qualifier (ID Version Indicatory) Principal Diagnosis ode and Present on dmission Indicator. (Required) Other Diagnosis codes. V and E codes are appropriate. Page 3 of 18

4 Form Locator 69. Form Locator 70a-c. Form Locator 71. Form Locator 72 a-c. Form Locator 73. Form Locator 74. Form Locator 74a-e. Form Locator 75. Form Locator 76. dmitting Diagnosis Patient s reason for visit Prospective Payment System (PPS) ode (Used by Medicare) External cause of injury code (EI). (The first E-code should always be printed here.) Principal Procedure ode and Date Other Procedure odes and Dates ttending Provider Name and Identifiers Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier Secondary Identifier = ontract Number with Payer Line 2: ttending Physician s last name, first name. Form Locator 77. Operating Physician Name and Identifier Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier Secondary Identifier = ontract Number with Payer Line 2: Operating Physician s last name, first name. Form Locator 78. Other Provider (Individual) Names and Identifiers Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier Secondary Identifier = ontract Number with Payer Line 2: Other Physician s last name, first name. Form Locator 79. Other Provider (Individual) Names and Identifier Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier Secondary Identifier = ontract Number with Payer Line 2: Other Physician s last name, first name. Form Locator 80. Form Locator 81 a-d. Remarks Field ode-ode Field Page 4 of 18

5 rosswalk to the HIP X2232 Institutional Implementation Guide To the greatest degree possible, the electronic crosswalk from the paper form to the electronic conforms to the standard paper form use described above. However, since there are different data requirements in the electronic format, some deviation does occur. Specifically, if there is an element that is required on all claims a place has been found on the paper page for it to occur even if there is no formal form locator for its function. Form Locator to 837I Detail: Form Locator 1. illing Provider Name, ddress and Telephone Number. REQUIRED The map described below assumes that the illing Provider is the same entity as the Pay-to Provider. If these are different entities than the translator must find a method of sending the Pay-to Provider information in addition to the illing Provider information. (The address reported is the one that should match the payer s contract) Line 1: Provider Name 2010 NM103 Line 2: Street ddress 2010 N301 Line 3: ity, State and Zip ode 2010 N401,02,03 When all 9 digit postal codes are known they should be sent. Line 4: Telephone, Fax, ountry ode 2010 PER04, N404 Form Locator 2. illing Provider Designated Pay-To ddress (Required when different from Form Locator 1) Line 1: Pay to Name not mapped Line 2: Street ddress or post office box 2010 N301 Line 3: ity, State, Zip ode 2010 N401,02,03 Form Locator 3a. Patient ontrol Number REQUIRED This number is assigned by the provider to identify this particular claim. This is an alpha-numeric non-standard field for the providers. It is strongly recommended that this number be unique for each claim LM01 Form Locator 3b. The X12 map REF02 Medical/Health Record Number Form Locator 4. Type of ill REQUIRED Type of ill is a 4 digit code, leading zeros are not reported in the LM05-1 (position 12-3 in Form Locator 4) 2300 LM05-3 (position 4 in Form Locator 4) Form Locator 5. Federal Tax ID Number REQUIRED Provider Tax ID Number [EIN or TIN can be used] 2010 REF02 Form Locator 6. Statement overs Period(From-Through MMDDYY) REQUIRED 2300 DTP03 (DTP01=434) (YYMMDD - YYMMDD) Page 5 of 18

6 Form Locator 7. Form Locator 8a. Patient Identifier - REQUIRED The X12 Map: When Patient = Subscriber 2010 NM109 When Patient is not = Subscriber 2010 NM109 Form Locator 8b. Patient Name - REQUIRED Last and First Name. Use a comma as the indicator to separate the last and first. No space should be left between a prefix and a name as in Maceth When using a suffix write: Last Name (space) Suffix, First Name ie Smith III, James When patient = subscriber: 2010 NM103,04,05,07 (Last and First generation respectively) When patient is not = subscriber: 2010 NM103,04,05,07 (Last and First generation respectively) Form Locator 9a e. Patient ddress - REQUIRED It is recommended that address be formatted as (a)street, (b)city, (c)state, (d)zip (e)country When patient = subscriber: 2010 N301: N401,02,03,04 (Street, city, state, ZIP & country respectively) When patient is not = subscriber: 2010 N301: N401,02,03,04 (Street, city, state, ZIP & country respectively) Form Locator 10. Patient irth Date. (MMDDYY 3 ) REQUIRED When patient = subscriber: 2010 DMG02 (YYMMDD) When patient is not = subscriber: 2010 DMG02 (YYMMDD) Form Locator 11. Patient Sex - REQUIRED When patient = subscriber: 2010 DMG03 When patient is not = subscriber: 2010 DMG03 Form Locator 12. dmission/start of are Date (MMDDYY) 2300 DTP03 (DTP01 = 435) Form Locator 13. dmission Hour REQUIRED on inpatient claims, code should be cross walked to appropriate time frame in the 837(see U04 manual) 2300 DTP03 (DTP01 = 435) 3 MMDDYY is the format to print the date on the U04 paper form. Page 6 of 18

7 Form Locator 14. Priority (Type) of Visit - REQUIRED This is code indicating the priority of the admission/visit L101 Form Locator 15. Point of Origin for dmission or Visit - REQUIRED Source of Referral for dmission or Visit 2300 L102 Form Locator 16. Discharge Hour REQUIRED on inpatient claims, code should be cross walked to appropriate time frame in the 837(see U04 manual) 2300 DTP03 (DTP01 = 096) Form Locator 17. Patient Discharge Status - REQUIRED 2300 L103 Form Locator ondition odes 2300 HI01-2 through HI11-2 (HI01-1 through HI11-1 = G) Form Locator 29. ccident State REQUIRED for auto accidents 2300 REF02 (REF01=LU) Form Locator 30. Form Locator Occurrence ode and Date 2300 HI01-2 through HI08-2 (HI01-1 through HI08-1= H) 2300 HI01-4 through HI08-4 (HI01-3 through HI08-3=D8} Form Locator Occurrence Span ode and Dates HI01-2 through HI04-2 (HI01-1 through HI04-1= I) 2300 HI01-4 through HI04-4 (HI01-3 through HI04-3=RD8} dditional Occurrence odes can be placed in the Occurrence Span Form Locators utilizing only the From Date. [Payer note: Occurrence and Occurrence Span codes are mutually exclusive. Form Locator 37. Form Locator 38. Responsible Party Name and ddress Not mapped Form Locator Value odes and mounts overed Days, Non-overed Days, o-insurance Days, Life Time Reserve Days are now value codes for the Paper laim Form The X12 map for value codes: 2300 HI01-2 (HI01-1 through HI12-1= E) HI01-5 through HI12-5, HI02-2 through HI12-2 Form Locator 42. Revenue odes REQUIRED Page 7 of 18

8 2400 SV201 Form Locator 43. Not cross walked Revenue Description (REQUIRED ON PPER) Indicates not cross walked but references loops below. dditionally, 2410 in the 5010 is a Drug Identification. ND Reporting: If a provider is billing using an ND code (done under contract with a payer), enter the qualifier N4, 11 digit ND, units qualifier and units on the same line as the REV code and Procedure ode (required when reporting an ND). Do not include spaces / dashes ompound reporting- should follow the ND reporting above on consecutive lines 2410 LIN03 = ND number (LIN02=N4) TP05-1 = Units qualifier (F2, GR, ML, ME, UN) 2410 TP04 = Number of units Form Locator 43. Line 23 (Line used for page number paper only) Input the page number and total pages Example: Page 3 of 10 Not cross walked Form Locator 44. HPS/ccommodation Rates/HIPPS Rate ode Required 2400 SV202-2 Procedures / HIPPS Rate 2400 SV202-3,4,5,6 Modifiers The translator vendor must decide on a method to fill the SV202-1 qualifier. Form Locator 45. Service Date Service Date Required for Outpatient laims 2400 DTP03 (DTP01=472 Service Form Locator 45. Line 23 reation Date (REQUIRED ON PPER) If a multiple page claim is sent the creation date should be reported on all pages Header HT04 Form Locator 46. Service Units / Days - REQUIRED 2400 SV205 If the REV code = (accommodation codes) then the qualifier will be for DYS If the REV code = all others then the qualifier will be for UNITS If there is a need to transmit blood factors which involve International Units, send UNITS; payers will follow up if they think it necessary. Form Locator 47. Total harges (This cannot be a negative number. **) REQUIRED The X12 map for the line level charges: 2400 SV203 On Paper Line 23 Page Total harges occurs on the last page of the claim. X12 map for the claim level charges When Revenue code = 0001, then this value = the value in 2300 LM02 Form Locator 48. Non overed charges (This cannot be a negative number. **) Page 8 of 18

9 2400 SV207 Form Locator 49. Form Locator 50a - c. Payer Name - t least one is REQUIRED The line identifies the primary payer (to the best of the provider s knowledge), the line is the secondary payer and the line is the tertiary payer NM103 (destination payer name) 2330 NM103 (non-destination payer name) The translator vendor must determine a method to indicate the destination payer. Destination payer is cross walked to the destination payer loops 2010 loop. The other two lines are cross walked to the Other Payer loop 2330 loop. See ppendix for examples. Form Locator 51. Health Plan ID Number - REQUIRED Use the national health plan identifier when established otherwise the number that the health plan has assigned to their particular plans operations. The X12 map 2010 NM NM109 Form Locator 52a-c. Release of Information ertification Indicator - One is REQUIRED for each payer The information for the row marked destination payer (see FL 50) is cross walked to the 2300 loop. The other two rows are cross walked to the 2320 loop LM09 (for destination payer) 2320 OI06 (non-destination payers) dditional Fields required when creating an X12 from a paper claim Form Locator 52+ (between FL 52 and FL 53). Medicare ssignment Indicator. ++ Not Used on Paper laims Only used on Medicare claims when Medicare is the destination payer or as required by trading partner agreement LM07 (output code in small space between FL 52 and FL 53) Form Locator 53. ssignment of enefits ertification indicator - One is REQUIRED for each payer. The information for the row marked destination payer (see FL 50) is cross walked to the 2300 loop. The other two rows are cross walked to the 2320 loop LM08 (destination payer line) LM08 is REQUIRED 2320 OI03 (non-destination payer line(s)) OI03 is REQUIRED when there is more than one payer on the claim Form Locator 54. Prior Payments - Payer The information for the row marked destination payer (see FL 50) is cross walked to the 2300 loop. The other two rows are cross walked to the 2320 loop MT02 (MT01= D for non-destination payer lines) Page 9 of 18

10 Form Locator 55a-c. Estimated mount Due - Payer mount estimated to be due from the indicated payer (estimated responsibility less prior payments) 2300 MT02 MT01= F MT02 (MT01= EF (non-destination payer line(s)) This may be equal to the Patient Responsibility from other payers Form Locator 56. NPI illing Provider- REQUIRED National Provider Identifier The X12 Map 2010 NM109 Form Locator 57a-c. Other (illing) Provider ID This is used for the illing providers tax ID. The X12 Map 2010 REF02 Form Locator 58a-c. Insured s Name - One is REQUIRED for each payer Use a comma to separate last and first. No space should be left between a prefix and a name as in Maceth, VonSchmidt, McEnroe. The information for the row marked destination payer (see FL 50) is cross walked to the 2010 loop. The other two rows are cross walked to the 2330 loop. Last and First Name: 2010 NM103,04,05 (respectively) for destination payer Last and First Name: 2330 NM103,04,05 (respectively) for non-destination payers Form Locator 59a-c. Patient's Relationship to the Insured - One is REQUIRED for each payer The information for the row marked destination payer (see FL 50) is cross walked to the 2000 or 2000 loop. The other two rows are cross walked to the 2320 loop. The translator vendor must determine how to associate the relationship to the correct X12 loop. For destination payers, if the relationship is self then map patient information to the 2010 loop; if the relationship is anything else, then map to 2010 loop. For the non-destination payer information map to the 2320 loop SR02 (if patient = subscriber, destination payer) 2000 PT01 (if patient is not = subscriber, destination payer) 2320 SR02 (non-destination payers) Form Locator 60a-c. Insured s Unique ID One is REQUIRED The insured s payer-assigned unique ID number. The information for the row marked destination payer (see FL 50) is cross walked to the 2010 or 2010 loops. The other two rows are cross walked to the 2330 loop. If secondary identifiers are sent, the payer must inform the provider which REF01 qualifier to use. Translator vendors must determine how to convey the correct REF01 qualifier NM109 (subscriber primary identification number for destination payer) 2010 REF02 (subscriber secondary identification number for destination payer) Separate primary and secondary numbers with / (forward slash) NM109 (other subscriber primary identification number for non-destination payer) 2330 REF02 (subscriber secondary identification number for destination payer) Separate primary and secondary numbers with / (forward slash) Property and asualty laim Number REF02 (when REF01 = Y4) Page 10 of 18

11 Form Locator 61a-c. Insured s Group Name The information for the row marked destination payer (see FL 50) is cross walked to the 2000 loop. The other two rows are cross walked to the 2320 loop SR04 (for destination payer) 2320 SR04 (for non-destination payers) Form Locator 62a-c. Insured s Group Number The information for the row marked destination payer (see FL 50) is cross walked to the 2000 loop. The other two rows are cross walked to the 2320 loop SR03 (for destination payer) 2320 SR03 (for non-destination payers) Form Locator 63a-c. Treatment uthorization ode (Prior uthorization/referral Number) The information for the row marked destination payer (see FL 50) is cross walked to the 2300 loop. The other two rows are cross walked to the 2330 loop. Output Prior uthorization Number first. If there is a also a Referral Number, print as shown to the right. Use a forward slash / to separate the two numbers if necessary. Use a / in front of the referral number if that number is sent alone. Prior uth Prior uthor / Referral / Referral 2300 REF02 (for destination payer) (REF01 = G1 Prior uthorization) (REF01 = 9F Referral) 2330 REF02 (for non-destination payer) (REF01 = G1 Prior uthorization) (REF01 = 9F Referral) Form Locator 64a-c. Document ontrol Number (DN) Original control number assigned by the health plan for internal control. Required for re-priced claims or corrected/replacement or void to previously adjudicated claim REF02 (for destination payer) F8=qualifier for replacements/voids, 9 or 9 for re-priced claims 2330 REF02 (for non-destination payer) F8= other payer control number Form Locator 65a-c. Employer Name (of the insured) Not cross walked Form Locator 66. Diagnosis and Procedure ode Qualifier (ID version indicator) - REQUIRED. For use when 5010 is implemented 2300 HI01-1 Form Locator 67. Principal Diagnosis ode and Present on dmission (PO) Indicator- REQUIRED 2300 HI (HI01-1=K or K) Form Locator 67a-q. position 8 (shaded area) Report the Present On dmission here 2300 HI01-9 Page 11 of 18

12 Form Locator 67a-q. Other Diagnosis codes V and E codes are appropriate HI01-2 (HI02-1 through HI12-1=F or F) (HI02-2 through HI12-2 = F or F) Form Locator 68. Form Locator 69. dmitting Diagnosis ode 2300 HI01-2 (HI01-1=J or J) Form Locator 70a-c. Patient Reason for Visit Patient reason for visit HI01-2 (HI01-1=PR or PR) (HI02-2) (HI03-2) Form Locator 71. Prospective Payment System (PPS) ode used to report the DRG HI01-2 (HI01-1=DR) Form Locator 72a-c. External ause of Injury (EI) ode The ID diagnosis codes pertaining to external cause of injury 2300 HI01-2 through HI03-2 (HI03-1 = N or N) 2300 HI01-9 through HI03-9 present on admission (PO) Form Locator 73. Form Locator 74. Principal Procedure ode and Date 2300 HI01-2 Procedure ode (HI01-1= R or R) 2300 HI01-4 date Form Locator 74a-e. Other Procedure odes and Dates 2300 HI01-2 ode (HI01-1 through HI05-1=Q or Q) (HI01-4 through HI05-4 =Date) Note: Q=ID 9.M Q= ID 10.PS O No longer present in Replacement Q or Q Form Locator 75. Form Locator 76. ttending Provider Name and ID- Required for all claims except transportation Line a: ttending Provider NPI. Followed by Qualifier for ttending Provider Secondary Identifier Line b: ttending Provider Last and First Name 2310 NM109 NPI REF01, 02 Secondary Identifier Qualifier, Secondary Identifier 2310 NM103,04 Last Name, First Name Page 12 of 18

13 Form Locator 77. Operating Provider Name and ID (Primary Surgeon) Line a: Operating Provider NPI. Followed by Qualifier for Operating Provider Secondary Identifier Line b: Operating Provider Last and First Name 2310 NM109 NPI 2310 REF01, 02 Secondary Identifier Qualifier, Secondary Identifier 2310 NM103,04 Last Name, First Name Form Locator Other Provider Name and ID Line a: Other Provider Type Qualifier, Other Provider NPI. Followed by Qualifier for Other Provider Secondary Identifier Line b: Other Provider Last and First Name Other Provider Type Qualifiers include: DN=referring provider, ZZ=other operating physician,82=rendering provider 2310 NM109 NPI. (When NM101=ZZ) 2310 REF01, 02 Secondary Identifier Qualifier, Secondary Identifier 2310 NM103,04 Last Name, First Name 2310D NM109 =NPI (When NM101=82) 2310D REF01, 02 Secondary Identifier Qualifier, Secondary Identifier 2310D NM103,04 Last Name, First Name 2310F NM109 =NPI (When NM101=DN) 2310F REF01, 02 Secondary Identifier Qualifier, Secondary Identifier 2310F NM103,04 Last Name, First Name Form Locator 80. Remarks 2300 NTE01 (Qualifier) 2300 NTE02 (Notes). Form Locator 81a-d. ode-ode (Paper only) This is where you can put additional codes required if not enough space in designated form locator ie condition codes, occurrence codes, value code span. X12 llows for more codes than paper and are indicated in the crosswalk above. Providers should report Taxonomy codes if required by Payer contracts illing Providers Taxonomy code. (3=Taxonomy) Example: 3 282N0000X 2000 PRV03 when PRV01=I ttending Providers Taxonomy code (used by some government /Medicaid payers) 2310 PRV03 when PRV02=ZZ ttachment control number (see valid code list in U-04 manual 2010 version or later) 2300 PWK06 Page 13 of 18

14 Implementation Date: January 1, 2012 or with implementation of 5010 History: (MM/DD/YY) Original V.1 * 1 V.2 * 1 * 2 V 3.0 * 4 ORIGINTION DTE 12/04/94 01/14/98 7/02 03/14/06 05/17/07 05/18/10 PPROVL DTE 02/09/95 08/10/99 06/12/03 02/07/07 08/06/08 5/18/2011 EFFETIVE DTE 03/09/95 09/10/99 07/12/03 03/07/07 09/06/08 6/18/2011 * = mendment Page 14 of 18

15 PPENDIX U04 Paper laim Examples Page 15 of 18

16 U04 Form Locator Elements 3a PT. 4 TYPE 1 Provider Name, ddress and Telephone 2 Pay-to Name and ddress NTL # Patient ontrol Number (unique claim number) OF ILL Number b. MED. RE. # Medical/Health Record Number TO 6 STTEMENT OVERS PERIOD 7 5 FED. TX NO. FROM THR OUGH Provider Tax # From Date To-date a Patient Identifier 9 PTIENT DDRESS a Patient ddress a b 8 PTIENT NME b Patient Name: Last and First b ity c State d Zip e ountry 10 IRTHDTE 11 SEX Patient DO Sex dmit date hr typ e 31 OURRENE DTE DMISSION 12 DTE 13 HR 14 TYPE 15 SR 16 DHR 17 STT ONDITION S OURRENE DTE 38 Responsible Party Name and ddress 33 OURRENE DTE 29 DT 30 STTE srce D hr sta ondition codes sta 34 OURRENE DTE 35 OURRENE SPN FROM THROUGH 36 OURRENE SPN FROM THROUGH Occurrence codes and dates Occurrence Span codes and dates Occurrence codes and dates Occurrence Span codes and dates a b c d 39 VLUE S MOUNT 40 VLUE S MOUNT Value odes and mounts Value odes and mounts Value odes and mounts Value odes and mounts VLUE S MOUNT 42 REV. D. 43 DESRIPTION 44 HPS / RTE / HIPPS 45 SERV. DTE 46 SERV. UNITS 47 TOTL HRGES 48 NON-OVERED HRGES 49 REV Revenue Description Proc ode, Modes, Rates Srv Date reation Date Service Units Total harges $$ Non-covered harges $$ a b Reserve d 4 4 *********************ND Example Using the 2410 loop 2x ********************************************* REV Proc ode, Modes, Date unit Line <ND > <Rx# > Rates Unit qual Unit harge Drug unit price <ND > <Rx# > Unit qual qual/count Drug unit price NOTE: ND info is only used if Unit count required by contract. The sum of all ND (Drug unit price x drug units) = service line charge (usually) LM Release of Information ertification Indicator ssignment of enefits ertification indicator Y or N PGE OF RETION DTE TOTLS 50 PYER NME 51 HELTH PLN ID 54 PRIOR PYMENTS 55 EST. MOUNT DUE 56 NPI NPI illing Provider 52 REL. 53 SG. INFO EN. Payer Name illing provider 2 nd ID Payer Est. mount Due 57 Other Provider ID Payer Name illing provider 2 nd ID payments. Payer Est. mount Due OTHER Other Provider ID Payer Name illing provider 2 nd ID payments. Payer Est. mount Due PRV ID Other Provider ID 58 INSURED S NME 59 P. REL 60 INSURED S UNIQUE ID payments. 61 GROUP NME 62 INSURNE GROUP NO. Subscriber name for payer Rel. Insured s Unique ID Insured s Group Name Insured s Group Number Subscriber name for payer Rel. Insured s Unique ID Insured s Group Name Insured s Group Number Subscriber name for payer Rel. Insured s Unique ID Insured s Group Name Insured s Group Number 63 TRETMENT UTHORIZTION S 64 DOUMENT ONTROL NUMER 65 EMPLOYER NME Treatment uthorization ode Document ontrol Number Employer Name (of the insured) Treatment uthorization ode Document ontrol Number Employer Name (of the insured) Treatment uthorization ode Document ontrol Number Employer Name (of the insured) 66 DX DX DX DX DX DX DX DX DX DX 68 DX DX DX DX DX DX DX DX DX I J 69 DMIT DX 74 PRINIPL PROEDURE DTE K DX L DX M 70 PTIENT 71 PPS 72 dmit DX RESON DX Patient reason code(s) PPS EI e-code e-code e-code 73 a. OTHER PROEDURE b. OTHER PROEDURE code 75 DTE DTE 76 TTENDING NPI ttending NPI QUL G2 Payer ID Prin. proc. Date Other proc. Date Other proc. Date ttending Last Name FIRST ttending First LST nd c. OTHER PROEDURE d. OTHER PROEDURE e. OTHER PROEDURE DTE DTE DTE 77 OPERTING QUL NPI Operating NPI Name G2 Payer ID Other proc Date Other proc. Date Other proc Date LST Operating Last Name FIRST Operating First REMRKS a ode-ode Fields 78 OTHER DN NPI Referring NPI Name QUL G2 Payer ID Remarks Field b ode-ode LST Referring Last Name FIRST Referring First c Fields ode-ode 79 OTHER 82 QUL NPI Rendering NPI Name G2 Payer ID d Fields ode-ode Fields FIRST LST Rendering Last Name Rendering First Name U-04 MS-1450 PPROVED OM NO. THE ERTIFITIONS ON THE REVERSE PPLY TO THIS ILL ND RE MDE PRT HEREOF. National Uniform NU illing ommittee LI E N Page 16 of 18 O P H

17 a b U04 Form Locator Elements NM a PT. NTL # 2300 LM01 b. MED N N REF02 RE. # LM05 6 STTEMENT OVERS PERIOD N401,02, N401,02,03 5 FED. TX NO. FROM THR OUGH 2010/ 2300 DTP N REF01,02 PER03,04 8 PTIENT NME a 2010 NM109 or PTIENT DDRESS a 2010 N301: N401,02,03,04 or 2010 N301: N401,02,03,04 NM109 b 2010 NM103,04,05,07 or 2010 NM103,04,05,07 b c d e 10 IRTHDTE 11 SEX 2010/ DMG DTP03 31 OURRENE DTE 38 DMISSION 12 DTE 13 HR 14 TYPE 15 SR 16 DHR 17 STT ONDITION S L101 L102 DTP03 L HI01-2 (HI01-1 = G), HI02-2 (HI02-1 = G), HI03-2 (HI03-1 = G), HI04-2 (HI04-32 OURRENE DTE 33 OURRENE DTE 1 = G), HI05-2 (HI05-1 = G), HI06-2 (HI06-1 = G), HI07-2 (HI07-1 = G) 35 OURRENE SPN FROM THROUGH 34 OURRENE DTE 2300 HI01-2 (HI01-1 = H) HI01-4, HI02-2 (HI02-1 = H) HI02-4, HI03-2 (HI03-1 = H) HI03-4, HI04-2 (HI04-1 = H) HI04-4, HI05-2 (HI05-1 = H) HI05-4, HI06-2 (HI06-1 = H) HI06-4, HI07-2 (HI07-1 = H) HI07-4, HI08-2 (HI08-1 = H) HI DT 30 STTE LM OURRENE SPN FROM THROUGH TYPE OF ILL 2300 HI01-2 (HI01-1 = I) HI01-4, HI02-2 (HI02-1 = I) HI02-4, a b c d 39 VLUE S MOUNT 40 VLUE S MOUNT 41 VLUE S MOUNT 2300 HI01-2 (HI01-1 = E) HI01-5, HI02-2 (HI02-1 = E) HI02-5, HI03-2 (HI03-1 = E) HI03-5, HI04-2 (HI04-1 = E) HI04-5, HI05-2 (HI05-1 = E) HI05-5, HI06-2 (HI06-1 = E) HI06-5, HI07-2 (HI07-1 = E) HI07-5, HI08-2 (HI08-1 = E) HI08-5, HI09-2 (HI09-1 = E) HI09-5, HI010-2 (HI010-1 = E) HI010-5, HI011-2 (HI011-1 = E) HI011-5, HI012-2 (HI012-1 = E) HI REV. D. 43 DESRIPTION 44 HPS / RTE / HIPPS 45 SERV. DTE 46 SERV. UNITS 47 TOTL HRGES 48 NON-OVERED HRGES SV202-3,4,5,6 Modifiers DTP SV206 Rates (Value in FL 44 is (DTP01=472) 2400 SV201 No crosswalk 2400 SV202-2 Procedures assumed to be a rate when REV = ) No crosswalk for creation date 2400 SV SV SV207 a b 5 5 SV201 SV202 <2410 REF02/LIN03 > < 2410 REF02 > <2410 LIN03 > < 2410 REF02 > <2410 LIN03 > < 2410 REF02 > SV206 SV203 TP05-1 TP04 TP05-1 TP04 TP05-1 TP04 TP LM LM OI PGE OF RETION DTE TOTLS 50 PYER NME 51 HELTH PLN ID 52 REL. INFO U-04 MS-1450 PPROVED OM NO. THE ERTIFITIONS ON THE REVERSE PPLY TO THIS ILL ND RE MDE PRT HEREOF. National Uniform NU illing ommittee LI SG. EN. Page 17 of PRIOR PYMENTS 55 EST. MOUNT DUE 56 NPI 2010 NM NM103 or 2330 NM NM MT02 (4) 2300 MT02 (5) REF02 Or 2330 NM MT02 (F3) 2320 MT02 (F3) OTHER 2010 REF02 nd 2010 NM MT02 (F5) PRV ID 2010 REF02 58 INSURED S NME 59 P. REL 60 INSURED S UNIQUE ID 61 GROUP NME 62 INSURNE GROUP NO NM103,04,05 Rel NM109/REF SR SR NM103,04,05 Rel NM109/REF SR SR03 Rel. 63 TRETMENT UTHORIZTION S 64 DOUMENT ONTROL NUMER 65 EMPLOYER NME 2300 REF02/ REF01 = G1/ REF01 = 9F 2300 REF02 Not cross walked 2330 REF02/ REF01 = G1/ REF01 = 9F 66 DX HI01-2 HI02-2 HI03-2 HI10-2 HI11-2 HI12-2 I J K HI04-2 DX 2330 REF01 HI05-2 HI06-2 HI07-2 HI08-2 HI L M N E O P H 69 DMIT HI PTIENT HI PPS HI HI03-2 DX RESON DX EI HI03-2 HI PRINIPL PROEDURE a. OTHER PROEDURE b. OTHER PROEDURE 75 DTE DTE DTE 76 TTENDING NPI 2310 NM109 QUL 2310 REF02 HI01-2 HI01-4 HI01-2 HI01-4 HI01-2 HI01-4 LST 2310 NM103 FIRST 2310 NM104 c. OTHER PROEDURE d. OTHER PROEDURE e. OTHER PROEDURE DTE DTE DTE 77 OPERTING QUL NPI 2310 NM REF02 HI01-2 HI01-4 HI01-2 HI01-4 HI01-2 HI01-4 LST 2310 NM103 FIRST 2310 NM REMRKS a 78 OTHER QUL NPI 2310 NM NTE01 (Qualifier) b X12 llows for more codes than paper REF02 LST 2310 NM103 FIRST and are indicated in the crosswalk 2310 NM NTE02 (Notes) c 79 OTHER QUL above (Paper only field). NPI 2310 NM d FIRST REF02 LST 2310 NM NM103

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