Intellect™
CHARGES MENU OPTIONS
Encounter
UB Encounter
UB04 Quick Reference
and
BILLING MENU OPTIONS
Insurance
Paper Claim Resources
UB04 Quick Reference
This document provides a quick reference to the Intellect screens and field names that populate the UB-04 (CMS-1450) claim form. The patient’s category and/or insurance type, as well as the billing method (clinic or doctor) may affect how some fields are populated. For a more detailed explanation, click the box number under the UB-04 Location column.
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UB04 Location |
Intellect Location Menu options and <Fieldname> |
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For Billing Method by Clinic: Utility --► Set Up --► Clinic <Name>, <Address>, <City>, <State>, <Zip Code> and <Phone>.
For Billing Method by Doctor:Utility --► Provider --► Provider <Organization Name> or <Last Name> <First Name>, <Address>, <City>, <State>, <Zip Code> and <Phone Number>. |
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For Billing Method by Clinic: Utility --► Set Up --► Clinic <Name>, <Address>, <City>, <State>, <Zip Code> and <Phone>.
For Billing Method by Doctor: Utility --► Provider --► Provider <Organization Name> or <Last Name> <First Name>, <Address>, <City>, <State>, <Zip Code>, and <Phone Number>. |
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Registration --► Regular --► Patient OR Registration --► Worker --► Worker <Patient Account No> |
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Registration --► Regular --► Patient OR Registration --► Worker --► Worker <Patient Account No> |
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Charges --► Encounter --► UB-Encounter <Bill Type> OR Utility --► Set Up --► Clinic <Facility Identification Number> If applicable, Charges --► Encounter --► UB-Encounter <Claim Frequency Code> replaces 3rd digit. |
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For Billing Method by Clinic: Utility --► Set Up --► Clinic <IRS Number>
For Billing Method by Doctor: Utility --► Provider --► Provider <I.R.S. Id> |
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FROM: Changes --► Charge <From Date>
TO: Charges --► Charge <To> |
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7 |
NOT USED |
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Registration --► Worker --► Worker <Social Security No> |
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Registration --► Regular --► Patient OR Registration --► Worker --► Worker <Last Name>, <First Name>, <Middle Initial> |
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Registration --► Regular --► Patient OR Registration --► Worker --► Worker <Address> |
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Registration --► Regular --► Patient OR Registration --► Worker --► Worker <City> |
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Registration --► Regular --► Patient OR Registration --► Worker --► Worker <State> |
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Registration --► Regular --► Patient OR Registration --► Worker --► Worker <Zip Code> |
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9e |
NOT USED |
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Registration --► Regular --► Patient OR Registration --► Worker --► Worker <DOB> |
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Registration --► Regular --► Patient OR Registration --► Worker --► Worker <Gender> |
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Charges --► Encounter --► UB-Encounter <Admission Date> |
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Charges --► Encounter --► UB-Encounter <Admission Time> |
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Charges --► Encounter --► UB-Encounter <Admission Type> |
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Charges --► Encounter --► UB-Encounter <Admission Scr> |
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Charges --► Encounter --► UB-Encounter <Discharge Hour> |
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Charges --► Encounter --► UB-Encounter <Status> |
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Charges --► Encounter --► UB-Encounter <Condition Code 1> |
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Charges --► Encounter --► UB-Encounter <Condition Code 2> |
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Charges --► Encounter --► UB-Encounter <Condition Code 3> |
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Charges --► Encounter --► UB-Encounter <Condition Code 4> |
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Charges --► Encounter --► UB-Encounter <Condition Code 5> |
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Charges --► Encounter --► UB-Encounter <Condition Code 6> |
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Charges --► Encounter --► UB-Encounter <Condition Code 7> |
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25 |
No field available in Intellect |
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26 |
No field available in Intellect |
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27 |
No field available in Intellect |
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28 |
No field available in Intellect |
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29 |
NOT USED |
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30 |
NOT USED |
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Charges --► Encounter --► UB-Encounter <Occurrence Code 1> and <Date> |
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Charges --► Encounter --► UB-Encounter <Occurrence Code 2> and <Date> |
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Charges --► Encounter --► UB-Encounter <Occurrence Code 3> and <Date> |
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Charges --► Encounter --► UB-Encounter <Occurrence Code 4> and <Date> |
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Charges --► Encounter --► UB-Encounter <Occurrence Code Span A>, <Occurrence Span From A>, and <Occurrence Span To A> |
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Charges --► Encounter --► UB-Encounter <Occurrence Code Span B>, <Occurrence Span From B>, and <Occurrence Span To B> |
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37 |
Charges --► Encounter --► UB-Encounter <Delay Reason Code> |
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Utility --► Insurance --► Insurance <Name>, <Address>, <City>, <State>, and <Zip> |
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Charges --► Encounter --► UB-Encounter <Value Code 1> and <Amount> |
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Charges --► Encounter --► UB-Encounter <Value Code 4> and <Amount> |
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Charges> --► Encounter --► UB-Encounter <Value Code 7> and <Amount> |
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No field available in Intellect |
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Charges --► Encounter --► UB-Encounter <Value Code 2> and <Amount> |
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Charges --► Encounter --► UB-Encounter <Value Code 5> and <Amount> |
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Charges --► Encounter --► UB-Encounter <Value Code 8> and <Amount> |
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No field available in Intellect |
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Charges --► Encounter --► UB-Encounter <Value Code 3> and <Amount> |
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Charges --► Encounter --► UB-Encounter <Value Code 6> and <Amount> |
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41c |
No field available in Intellect |
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41d |
No field available in Intellect |
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Lines 1 through 22: Utility --► Procedure --► Procedure <Revenue Code> |
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Lines 1 through 22: Utility --► Procedure --► Procedure <Description> OR Utility --► Messages --► Remark <Description> OR Utility --► Procedure --► Procedure <Rural Procedure Description> |
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Lines 1 through 22: Utility --► Procedure --► Procedure <Code R>, <Code C>, <Code E>, <Code O> or <Revenue Code> AND Charges --► Charge <Mod> |
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Lines 1 through 22: Charges --► Charge <From Date> |
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Lines 1 through 22: Charges --► Charge <Qty> |
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Lines 1 through 22: Charges --► Charge <Charge> |
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48 |
NOT USED |
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49 |
NOT USED |
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Utility --► Insurance --► Insurance <Name> (primary insurance) |
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Utility --► Insurance --► Insurance <Name> (secondary insurance) |
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Utility --► Insurance --► Insurance <Name> (tertiary insurance) |
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For Billing Method by Clinic: Utility --► Insurance --► Insurance <1500 Form Box 33 Group>
For Billing Method by Doctor: Utility --► Provider --► Provider Facility <HCFA Box33> OR Utility --► Provider --► Provider --► Provider Provider <HCFA Box33> OR Utility --► Provider --► Provider <HCFA Box 33 1>, <HCFA Box 33 2> or <HCFA Box 33 3> |
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For Billing Method by Clinic: Utility --► Insurance --► Insurance <1500 Form Box 33 Group>
For Billing Method by Doctor: Utility --► Provider --► Provider Facility <HCFA Box33> OR Utility --► Provider --► Provider --► Provider Provider <HCFA Box 33> OR Utility --► Provider --► Provider <HCFA Box 33 1>, <HCFA Box 33 2> or <HCFA Box 33 3> |
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For Billing Method by Clinic: Utility --► Insurance --► Insurance <1500 Form Box 33 Group>
For Billing Method by Doctor: Utility --► Provider --► Provider Facility <HCFA Box33> OR Utility --► Provider --► Provider --► Provider Provider <HCFA Box33> OR Utility --► Provider --► Provider <HCFA Box 33 1>, <HCFA Box 33 2> or <HCFA Box 33 3> |
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Registration --► Regular --► Patient Insurance <Assignment> |
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Registration --► Regular --► Patient Insurance <Assignment> |
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Registration --► Regular --► Patient Insurance <Assignment> |
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Registration --► Regular --► Patient Insurance <Assignment> |
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Registration --► Regular --► Patient Insurance <Assignment> |
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Registration --► Regular --► Patient Insurance <Assignment> |
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Automatically calculated. |
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54B |
NOT USED |
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54C |
NOT USED |
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Automatically calculated. |
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Automatically calculated. |
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55C |
NOT USED |
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For Billing Method by Clinic: Utility --► Insurance --► Insurance <Group NPI>
For Billing Method by Doctor: Utility --► Provider --► Provider Facility <Group NPI> OR Utility --► Provider --► Provider Provider <Group NPI> OR Utility --► Provider --► Provider <Group NPI> |
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57A |
NOT USED |
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57B |
NOT USED |
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57C |
NOT USED |
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Registration --► Regular --► Patient <Last Name> <First Name> <Middle Initial> OR Registration --► Regular --► Patient Insurance <Last Name> <Insured First Name> <Middle Initial> OR Registration --► Worker --► Worker Insurance <Employer> name |
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Registration --► Regular --► Patient <Last Name> <First Name> <Middle Initial> OR Registration --► Regular --► Patient Insurance <Last Name> <Insured First Name> <Middle Initial> |
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Registration --► Regular --► Patient <Last Name> <First Name> <Middle Initial> OR Registration --► Regular --► Patient Insurance <Last Name> <Insured First Name> <Middle Initial> |
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Registration --► Regular --► Patient Insurance <Relation to Insured> |
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Registration --► Regular --► Patient Insurance <Relation to Insured> |
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Registration --► Regular --► Patient Insurance <Relation to Insured> |
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Registration --► Regular --► Patient Insurance <Subscriber No> OR Registration --► Worker --► Worker Insurance <BOX IA/CLAIM#> |
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Registration --► Regular --► Patient Insurance <Subscriber No> OR Registration --► Worker --► Worker Insurance <BOX IA/CLAIM#> |
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Registration --► Regular --► Patient Insurance <Subscriber No> OR Registration --► Worker --► Worker Insurance <BOX IA/CLAIM#> |
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61A |
NOT USED |
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61B |
NOT USED |
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61C |
NOT USED |
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Registration --► Regular --► Patient Insurance <Group No> OR Registration --► Worker --► Worker Insurance <Claim No 1> or ‘Unknown’ |
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Registration --► Regular --► Insurance <Group No> OR Registration --► Worker --► Worker Insurance <Claim No 1> or ‘Unknown’ |
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Registration --► Regular --► Patient Insurance <Group No> OR Registration --► Worker --► Worker Insurance <Claim No 1> or ‘Unknown’ |
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Charges --► Encounter --► UB-Encounter <Authorization No> |
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63B |
NOT USED |
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63C |
NOT USED |
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Charges --► Encounter --► UB-Encounter <Internal Control> |
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64B |
NOT USED |
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64C |
NOT USED |
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Registration --► Regular --► Patient <Employer> OR Registration --► Regular --► Patient Insurance <Insured’s Employer> OR Registration --► Worker --► Worker Insurance <Employer> |
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Registration --► Regular --► Patient <Employer> OR Registration --► Regular --► Patient Insurance <Insured’s Employer> OR Registration --► Worker --► Worker Insurance <Employer> |
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Registration --► Regular --► Patient <Employer> OR Registration --► Regular --► Patient Insurance <Insured’s Employer> OR Registration --► Worker --► Worker Insurance <Employer> |
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Utility --► Diagnosis --► Diagnosis <ICD9/ICD10> |
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Charges --► Encounter --► UB-Encounter <Principal Diagnosis>
Charges --► Charges <Diagnosis Code> |
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68 |
NOT USED |
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Charges --► Encounter --► UB-Encounter <Admission Diagnosis> |
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70 |
NOT USED |
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Charges --► Encounter --► UB-Encounter <PPS/DRG Code> |
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72 |
NOT USED |
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73 |
NOT USED |
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Charges --► Encounter --► UB-Encounter <Principal Procedure> and <Date> |
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Charges --► Encounter --► UB-Encounter <Other Procedure A> and Principal Procedure <Date> |
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Charges --► Encounter --► UB-Encounter <Other Procedure B> and Principal Procedure <Date> |
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Charges --► Encounter --► UB-Encounter <Other Procedure C> and Principal Procedure <Date> |
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Charges --► Encounter --► UB-Encounter <Other Procedure D> and Principal Procedure <Date> |
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Charges --► Encounter --► UB-Encounter <Other Procedure E> and Principal Procedure <Date> |
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75 |
NOT USED |
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NPI: Utility --► Referring <NPI> QUAL: Utility --► Insurance --► Insurance <Referring Type> AND Utility --► Referring <UPIN Number> or <Provider No.> or <State License> or <NPI> or <Commercial> or <Blue Shield> or <Tax ID> LAST: Utility --► Referring <Last Name> FIRST:Utility --► Referring <First Name> |
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NPI: Utility --► Provider --► Provider <NPI> QUAL: Utility --► Insurance --► Insurance <Box 24J Type> AND Utility --► Provider --► Provider Facility <HCFA Box 24 J> OR Utility --► Provider --► Provider Provider <HCFA Box24 J> OR Utility --► Provider --► Provider <HCFA Box 24 J1>, <HCFA Box 24 J2> or <HCFA Box 24 J3> LAST: Utility --► Provider --► Provider <Last Name> FIRST: Utility --► Provider --► Provider <First Name> |
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78 |
NOT USED |
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79 |
NOT USED |
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Charges --► Encounter --► UB-Encounter <Claim Notes> OR Registration --► Worker --► Worker Insurance <Address>, <City>, <State>, <Zip> for employer |
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‘B3’ followed by Utility --► Referring <Taxomony> AND (if applicable) Charges --► Encounter --► Generic <Report Type Code> + <Report Transmission Code> + <Identification Code> |
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‘B3’ followed by Utility --► Provider --► Provider <Taxonomy> |
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81c |
NOT USED |
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81d |
NOT USED |