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UB04 Review (Training Documentation)

 

 

and

 

 

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Insurance

 

Paper Claim Resources

 

UB04 Review (Training Documentation)

 

 

In this Topic Hide

Overview

UB04 Box Definitions

 

 

Overview

This review notes, per box, where the printed information may be found in Intellect, as well as any electronic submission loops and segments. 

 

1. Encounter screen

This review mentions the encounter screen. To determine if and what encounter has been attached to a charge, go to Charges --►Modify and pull up the patient and date of service in question. The encounter number is displayed under the EN# heading. To relate or change an encounter, move the cursor next to the charge. From the C (command) column press M to modify that line. Press [Enter] until the cursor is under the EN# heading and enter the appropriate encounter number. To exit the line, press [Enter] until the cursor is under the C (command) column.

 

2. Billing Methods

 

2.1 This review mentions billing methods. The billing method is determined by:

 

2.2.1 Billing method C (clinic):

Utility --►Set Up --► Parameter <Billing Method> = C. If this field is left blank, then
Utility --►Category <Billing Method> = C.

 

2.2.2 Billing method D (doctor):

Utility --►Set Up --► Parameter <Billing Method> = D. If this field is left blank, then
Utility --►Category <Billing Method
)> = D

 

3. Insurance

 

3.1 This review mentions primary, secondary, and tertiary (third) insurance. Insurance is defined as such by:

 

3.1.1 Primary insurance:

Registration --► Regular --► Patient Insurance screen <Primary/Secondary> = P1, P2, P3, etc.

                 

3.1.2 Secondary insurance:

Registration --► Regular --► Patient Insurance screen <Primary/Secondary> = S1, S2, S3, etc.

                 

3.1.3 Tertiary (third) insurance:

Registration --► Regular --► Patient Insurance screen <Primary/Secondary> = T1, T2, T3, etc.

 

4. Referring Doctor

 

4.1 This review also mentions Referring doctor. To determine the origin of the referring source, go to Utility --► Set Up --► Parameter <Referring>:

 

4.1.1 P - Referring source originates from Registration --► Regular --► Patient <Referring Name>. When this is not a doctor (e.g., Internet, friend, etc., Utility --► Referring <Doctor/Other (D/O)> = O), the treating physician’s information is used.

 

4.1.2 C - Referring source originates from that which was entered at the time of posting the charge (Charges --► Charge <Ref Prv>). When no referring source was entered at the time of posting, the treating physician’s information is used.

 

4.1.3 F - Referring source first originates from the charge screen (Charges --► Charge <Ref Prv>). When none is entered, Intellect uses Registration --► Regular --► Patient <Referring Name>. When this is not a doctor (e.g., Internet, friend, etc., Utility --► Referring <Doctor/Other (D/O)> = O), the treating physician’s information is used.

 

4.2 Adding or modifying a referring source after the charge(s) have been posted (when Utility --► Set Up --► Parameter <Referring> is C or F), may be done through:

 

4.2.1 Ledger --►Accounting <Ref> by moving the cursor next to the charge, from the C (command) column press M (modify), press [Enter] until the cursor is under the Ref heading, enter the Utility --► Referring <Referring Code> (pressing the [F2] search key displays the Searching Referring screen to search for the referring code), press [Enter] until the cursor returns to the C (command) column.

 

4.2.2 Ledger --►Open Item <Rdr> by moving the cursor next to the charge, from the C (command) column press M (modify), press [Enter] until the cursor is under the Rdr heading, enter the Utility --► Referring <Referring Code> (pressing the [F2] search key displays the Searching Referring screen to search for the referring code), press [Enter] until the cursor returns to the C (command) column.

 

4.2.3 Charges --►Modify <Rdr> by moving the cursor next to the charge, from the C (command) column press M (modify), press [Enter] until the cursor is under the Rdr heading, enter the Utility --► Referring <Referring Code>, (pressing the [F2] search key displays the Searching Referring screen to search for the referring code), press [Enter]until the cursor returns to the C (command) column.

 

 

UB04 Box Definitions

 

Note: Effective version 9.12.29 (March 2012), changes were made to Boxes 8a, 51, 59, 62, 80, and 81 for UB04 Worker patients. See individual boxes below for specific information. The changes to UB04 forms are not automatically added with the update. To have these changes added, call Prime Clinical Systems and request the form be updated.


Box 1

Billing Method C: Utility --► Set Up --► Clinic <Name>, <Address>, <Zip Code>, <City>, and <State>.

 

Billing Method D: Utility --► Provider --► Provider <Organization Name> (<Last Name>, <First Name> when <Organization Name> is blank), <Address>, <Zip Code>, <City>, and <State>.

 

837 Institutional Loop 2010 AA NM103, NM3, N4

and Phone number Loop 2010 AA PER04

 

Box 2

Not used.

 

Box 3a PAT CNTL NO.

Registration --►Regular --►Patient <Patient Account No>.

 

837 Institutional Loop 2300 CLM01

 

Box 3b       MED REC NO.

Registration --► Regular --► Patient <Patient Account No>.

 

837 Institutional Loop 2300 REF02

 

Box 4        TYPE OF BILL

Charges --► Encounter --► UB-Encounter <Bill Type>. If charges do not have an encounter then enter the Utility --► Set Up --► Clinic <Facility Identification Number>.

 

The type of bill code includes the two-digit facility type code and one-character claim frequency code. This is a required field when billing Medi-Cal

 

837 Institutional Loop 2300 CLM05

 

 

 

More About Bill Type Electronic Determination

 

Box 5        FED. TAX NO.

Billing Method C: Utility --► Set Up --►Clinic <I.R.S. Number>.

 

Billing Method D: Utility --►Provider  --►Provider <I.R.S. Id.>.

 

Not required by Medi-Cal

837 Institutional Loop 2010AA REF02

 

Box 6        STATEMENT COVERS PERIOD / FROM / THROUGH

Charges --►Charge <From Date> and <To> (date).

 

837 Institutional Loop 2300 DTP03

 

Box 7  

Not Used.

 

Box 8a (Patient ID)

Not Used.

 

Effective version  9.12.29, this change was made to the UB04 for Worker patients:
Prints the patient's social security number as shown in the <Social Security No> field on the Registration --►Worker --►Worker screen. To have the SSN print, call PCS and ask support to add it to the form; it is not automatically inserted.

 

Box 8b Patient Name

Registration --►Regular --►Patient <Last Name>, <First Name>, <Middle Initial>

 

837 Institutional Loop 2010BA NM103, NM104, NM105

 

Box 9a   PATIENT ADDRESS

Registration --►Regular --►Patient <Address>

 

837 Institutional Loop 2010BA N301

 

Box 9b

Registration --►Regular --►Patient <City>

 

837 Institutional Loop 2010BA N401

 

Box 9c

Registration --► Regular --► Patient  <State>

 

837 Institutional Loop 2010BA N402

 

Box 9d

Registration --► Regular --► Patient  <Zip Code>

 

837 Institutional Loop 2010BA N403

 

Box 10      BIRTHDATE

Registration --► Regular --► Patient  <DOB>

 

837 Institutional Loop 2010BA DMG02

 

Box 11      SEX

Registration --► Regular --► Patient  <Gender>

 

837 Institutional Loop 2010BA DMG03

 

Box 12      Admission DATE

Charges --► Encounter --► UB-Encounter <Admission Date>.

 

Not required by Medi-Cal.

 

Box 13      Admission HR

Charges --► Encounter --► UB-Encounter <Admission Time>.

 

Not required by Medi-Cal.

 

Box 14      Admission TYPE

Charges --► Encounter --► UB-Encounter <Admission Type>.

 

837 Institutional Loop 2300 CL101

 

NOTE: Contact support to request this field to print on paper claims.  

 

Box 15      Admission SRC

Charges --► Encounter --► UB-Encounter <Admission Src>.

 

837 Institutional Loop 2300 CL102

 

Box 16       DHR

 

Inpatient Only. Not Used

 

Box 17      STAT

Charges --► Encounter --► UB-Encounter <Status>.

 

837 Institutional Loop 2300 CL103

 

Box 18 CONDITION CODES

Charges --► Encounter --► UB-Encounter <Condition Code 1>.

 

837 Institutional Loop 2300 HI*BG

 

Box 19 CONDITION CODES

Charges --► Encounter --► UB-Encounter <Condition Code 2>.

 

Box 20      CONDITION CODES

Charges --► Encounter --► UB-Encounter <Condition Code 3>.

 

Box 21 CONDITION CODES

Charges --► Encounter --► UB-Encounter <Condition Code 4>.

 

Box 22 CONDITION CODES

Charges --► Encounter --► UB-Encounter <Condition Code 5>.

 

Box 23      CONDITION CODES

Charges --► Encounter --► UB-Encounter <Condition Code 6>.

 

Box 24      CONDITION CODES

Charges --► Encounter --► UB-Encounter <Condition Code 7>.

 

Box 25      CONDITION CODES

No field

 

Box 26      CONDITION CODES

No field

 

Box 27      CONDITION CODES

No field

 

Box 28      CONDITION CODES

No field

 

Box 29       ACDT

Not Used

 

Box 30     

Not Used

 

Box 31 OCCURRENCE CODE / DATE

Charges --► Encounter --► UB-Encounter <Occurrence Code 1> and <Date>.

 

837 Institutional Loop 2300 HI*BH

HI*BH:42:D8 (Date)

 

Box 32 OCCURRENCE CODE / DATE

Charges --► Encounter --► UB-Encounter <Occurrence Code 2> and <Date>.

 

Box 33 OCCURRENCE CODE / DATE

Charges --► Encounter --► UB-Encounter <Occurrence Code 3> and <Date>.

 

Box 34 OCCURRENCE CODE / DATE

Charges --► Encounter --► UB-Encounter <Occurrence Code 4> and <Date>.

 

Box 35 OCCURRENCE SPAN CODE/ FROM / THROUGH

Charges --► Encounter --► UB-Encounter <Occurrence Code Span A>.

Charges --► Encounter --► UB-Encounter <Occurrence Span From A>.

Charges --► Encounter --► UB-Encounter <Occurrence Span To A>.

 

Box 36 OCCURRENCE SPAN CODE/ FROM / THROUGH

Charges --► Encounter --► UB-Encounter <Occurrence Code Span B>.

Charges --► Encounter --► UB-Encounter <Occurrence Span From B>.

Charges --► Encounter --► UB-Encounter <Occurrence Span To B>.

 

Box 37

For Medi-Cal Delay Reason Code

 

Charges --► Encounter --► UB-Encounter <Delay Reason Code>

 

837 Institutional Loop 2300 CLM20

 

Box 38

Utility --►Insurance --►Insurance <Name>, <Address>, <City>, <State>, and <Zip> (for the insurance being billed).

 

Not required by Medi-Cal and does not print for Utility --►Insurance --►Insurance <Insurance Type> = 'D'

 

Box 39a    VALUE CODES   CODE / AMOUNT

Charges --► Encounter --► UB-Encounter <Value Code 1> and <Amount>.

 

837 Institutional Loop 2300 HI*BE

HI*BE:08:::1740~ (Amount)

 

Effective version 20.12.21: Box 39a - 41d

Per CMS, effective January 1, 2021, CMS implemented Value Code (VC) D6: The total number of minutes of dialysis provided during the billing period. Designation: NM (Non-Monetary). See Information from CMS for details. For example:

 

A patient is dialyzed 3 hours per day, 3 days a week, for 4 weeks. The ESRD facility would report 2160 minutes (that is, (60 x 3) x (3 x 4) = 2160) as “0002160.00” in VC D6.

 

To accommodate the D6 code, effective in the 20.12.21 Intellect release, when Value Code ‘D6’ is entered in any of the <Value Code 1-8> fields on the Charges --►Encounter --►UB Encounter screen and the <Amount> field is populated, the program changes the format and adds applicable zeros to the start of the value based on the minutes entered (e.g., 2160 minutes becomes 0002160.00).

 

When the UB04 is printed, the <Value Code> prints in Box 39a as D6.

When claims are submitted electronically via Intellect, the ANSI 837 consists of the same value as is in the Paper UB04. For example:

 

005010X2238372300HI ASC X12N

VALUE INFORMATION

HI*BE:48:::9.5*BE:A8:::82.1*BE:A9:::170.18*BE:D6:::0002160.00

 

Box 39b    VALUE CODES   CODE / AMOUNT

Charges --► Encounter --► UB-Encounter <Value Code 4> and <Amount>

 

Starting January 1, 2021, CMS began implementing Dialysis Value Code D6. Intellect version 20.12.21 includes the revisions to accommodate the D6 value code. See Box 39a for details.

 

Box 39c     VALUE CODES   CODE / AMOUNT

Charges --► Encounter --► UB-Encounter <Value Code 7> and <Amount>.

 

Starting January 1, 2021, CMS began implementing Dialysis Value Code D6. Intellect version 20.12.21 includes the revisions to accommodate the D6 value code. See Box 39a for details.

 

Box 39d    VALUE CODES   CODE / AMOUNT

 Not Used

 

Box 40a    VALUE CODES   CODE / AMOUNT

Charges --► Encounter --► UB-Encounter <Value Code 2> and <Amount>.

 

Starting January 1, 2021, CMS began implementing Dialysis Value Code D6. Intellect version 20.12.21 includes the revisions to accommodate the D6 value code. See Box 39a for details.

 

Box 40b    VALUE CODES   CODE / AMOUNT

Charges --► Encounter --► UB-Encounter <Value Code 5> and <Amount>.

 

Starting January 1, 2021, CMS began implementing Dialysis Value Code D6. Intellect version 20.12.21 includes the revisions to accommodate the D6 value code. See Box 39a for details.

 

Box 40c     VALUE CODES   CODE / AMOUNT

Charges --► Encounter --► UB-Encounter <Value Code 8> and <Amount>.

 

Starting January 1, 2021, CMS began implementing Dialysis Value Code D6. Intellect version 20.12.21 includes the revisions to accommodate the D6 value code. See Box 39a for details.

 

Box 40d    VALUE CODES   CODE / AMOUNT

Not used.

 

Box 41a    VALUE CODES   CODE / AMOUNT

Charges --► Encounter --► UB-Encounter <Value Code 3> and <Amount>.

 

Starting January 1, 2021, CMS began implementing Dialysis Value Code D6. Intellect version 20.12.21 includes the revisions to accommodate the D6 value code. See Box 39a for details.

 

Box 41b    VALUE CODES   CODE / AMOUNT

Charges --► Encounter --► UB-Encounter <Value Code 6> and <Amount>.

 

Starting January 1, 2021, CMS began implementing Dialysis Value Code D6. Intellect version 20.12.21 includes the revisions to accommodate the D6 value code. See Box 39a for details.

 

Box 41c     VALUE CODES   CODE / AMOUNT

Not used.

 

Box 41d    VALUE CODES   CODE / AMOUNT

Not used.

 

Box 42      REV. CD.

Utility --► Procedure <Revenue Code> as it was at the time the charge was posted. 

 

See Revenue Code Table

 

837 Institutional Claim Loop 2400 SV201

 

NOTE: If Utility --► Procedure <Revenue Code> is changed after charges are posted, contact PCS support to have the treat_hist th_UB04 field updated.

 

Box 43      DESCRIPTION

Line 1 through 23 Utility --► Procedure <Description>

 

Below Line 23 Intellect prints values for:  PAGE__OF___, CREATION DATE ___ ,TOTALS_______

 

NOTE: If billing on the Summarized UB04 Form 8:

Line 1 through 23 Utility --►Messages --► Remark <Description> dependent on Utility --► Procedure <Revenue Code>.     

 

Box 44      HCPCS / RATE/ HIPPS CODE

Prints the Utility --► Procedure <Code R>, < C>, <E> or <Revenue Code> dependent on Utility --►Insurance --►Insurance <Code (R/C/E/U)>.

 

NOTE: If billing on the Summarized UB04 Form 8:

Line 1 through 22 Utility --► Procedure <Code R>, < C>, <E> or <Revenue Code> for the first procedure posted for each unique Revenue Code.

 

837 Institutional Claim Loop 2400 SV202

 

Box 45      SERV. DATE

The posted date of service (shown under the heading of Ledger --► Accounting or Ledger --►Open Item <DOS>).

 

837 Institutional  Claim  Loop 2400 DTP*472*D8

 

Box 46      SERV. UNITS

The Utility --► Procedure <Days/Units> for the quantity of the  posted charge (shown under the heading of Ledger --►Accounting <Days>).

 

837 Institutional Claim Loop 2400 SV205

 

Box 47     TOTAL CHARGES

 

Line 1 through 23, the posted charge amount (shown under the heading of Ledger --► Accounting or Ledger --►Open Item <Amount> as well as Charges --► Charge --► Modify <Charge>.

 

837 Institutional Loop 2400 SV203

 

Boxes 48 and 49

Not used.

 

Box 50A    PAYER

Utility --► Insurance --►Insurance <Name> of primary insurance.

 

837 Institutional Loop 2010 BC NM103

 

Box 50B    PAYER

Utility --► Insurance --►Insurance <Name> of secondary insurance.

 

Box 50C    PAYER

Utility --► Insurance --►Insurance <Name> of tertiary (third) insurance.

 

Box 51A    HEALTH PLAN ID

Billing Method C

Utility --► Insurance --►Insurance <1500 Form Box 33 Group> number prints if: 

 

Billing Method D

The Billing Provider's Utility --► Provider --► Provider Facility <HCFA Box 33> number prints. 

 

- OR -

 

If none, the Utility --► Provider --► Provider-Provider <HCFA Box 33> number prints

 

- OR -

 

If none, the Utility --► Provider <HCFA Box 33 1>, 2 or 3 prints, dependent upon Utility --►Insurance --►Insurance <Selection (1/2/3)>. 

 

Effective version  9.12.29, this field prints blank on the UB04 for Worker's Compensation patients. This change is not automatically added with the update. To have this change, call Prime Clinical Systems and request the form be updated.

 

Box 52A    REL INFO

Registration --► Regular --► Patient Insurance <Assignment> of primary insurance.

 

837 Institutional Loop 2300 CLM09

 

Box 52B    REL INFO

Registration --► Regular --► Patient Insurance <Assignment> of secondary insurance.

 

Box 52C    REL INFO

Registration --► Regular --► Patient Insurance <Assignment> of tertiary (third) insurance.

 

Box 53A    ASG BEN

Registration --► Regular --► Patient Insurance <Assignment> of primary insurance.

 

837 Institutional Loop 2300 CLM08

 

Box 53B    ASG BEN

Registration --► Regular --► Patient Insurance <Assignment> of secondary insurance.

 

Box 53C    ASG BEN

Registration --► Regular --► Patient Insurance <Assignment> of tertiary (third) insurance.

 

Note: Form 8 Only: If Utility --► Insurance --► Insurance <Print Prim Ins on Sec> is set to 'Yes' when printing the secondary insurance claim, the Secondary insurance information prints in Boxes 50a, 51a, and 52a in place of the Primary insurance information.

 

Box 54A    PRIOR PAYMENTS

Prints the calculated total of all insurance payments.

 

Note: Form 8 Only: If Utility --► Insurance --► Insurance <Print Prim Ins on Sec> is set to 'Yes,' Box 54a (where the Primary insurance payment normally prints) is left blank.  

 

Boxes 54B and 54C

Not used.

 

Box 55A    EST. AMOUNT DUE

Prints the calculated total of all charges.

 

Note: Form 8 Only: If Utility --► Insurance --► Insurance <Print Prim Ins on Sec> is set to 'Yes,' the total charges print in Box 55a in place of the balance.  

 

Box 55B    EST. AMOUNT DUE

Prints the total charges minus insurance payments and adjustments. 

 

Box 55C

Not used.

 

Box 56  NPI

Billing Method C

Utility --► Insurance --► Insurance <Group NPI> number prints. 

 

Billing Method D

The Billing Provider's Utility --► Provider --► Facility-Provider <Group NPI> number prints. 

 

- OR -

 

If none, the Utility --► Provider --► Provider-Provider <Group NPI> number prints. 

 

- OR -

 

If none, the Utility --► Provider <Group NPI> prints.

 

837 Institutional Loop 2010 AA NM109


Box 57

Atypical Provider ID only

 

Box 58A    INSURED'S NAME

When the Registration --► Regular --► Patient primary insurance screen’s <Relation to Insured> is:

 

18: Registration --► Regular --► Patient <Name> (Last, First Init.) prints.

 

Other than 18: Registration --► Regular --► Patient insurance screen's <Insured’s Name> prints.

 

Box 58B    INSURED'S NAME

When the Registration --► Regular --► Patient secondary insurance screen’s <Relation to Insured> is:

 

18: Registration --► Regular --► Patient  <Name> (Last, First Init.) prints.

 

Other than 18Registration --► Regular --► Patient  insurance screen's <Insured’s Name> prints.

 

Box 58C    INSURED'S NAME

When the Registration --► Regular --► Patient tertiary insurance screen’s <Relation to Insured> is:

 

1: Registration --► Regular --► Patient  <Name> (Last, First Init.) prints.

 

Other than 1Registration --► Regular --► Patient  insurance screen's <Insured’s Name> prints.

 

Box 59A    P. REL

Registration --► Regular --► Patient primary insurance screen’s <Relation to Insured>.

 

837 Institutional Loop 2000B SBR02

 

Effective version  9.12.29, Box 59 prints '20' on the UB04 for all Worker's Compensation patients. This change is not automatically added with the update. To have this change, call Prime Clinical Systems and request the form be updated.

 

Box 59B    P. REL

Registration --► Regular --► Patient secondary insurance screen’s <Relation to Insured>.

 

Box 59C    P. REL

Registration --► Regular --► Patient tertiary insurance screen’s <Relation to Insured>.

 

Box 60A    CERT. - SSN - HIC. - ID NO.

Registration --► Regular --► Patient primary insurance screen’s <Subscriber No>.

 

837 Institutional Loop 2010BA NM109

 

Box 60B    CERT. - SSN - HIC. - ID NO.

Registration --► Regular --► Patient secondary insurance screen’s <Subscriber No>.

 

Box 60C    CERT. - SSN - HIC. - ID NO.

Registration --► Regular --► Patient tertiary insurance screen’s <Subscriber No>.

 

Boxes 61A   through   61C

Not used.

 

Box 62A    INSURANCE GROUP NO.

Registration --► Regular --► Patient primary insurance screen’s <Group No>.

 

Note: Form 8 Only: If Utility --► Insurance --► Insurance <Print Prim Ins on Sec> is set to 'Yes' when printing the secondary insurance claim, the Secondary insurance information prints in Boxes 60a, and 62a in place of the Primary insurance information.

 

Effective version  9.12.29, for all Worker's Compensation patients, Box 62 prints information from the <Claim No. 1> field on the Registration --►Worker --►Worker Insurance screen. When that field is blank, the system prints 'Unknown' on the UB04. This change is not automatically added with the update. To have this change, call Prime Clinical Systems and request the form be updated.

 

Box 62B    INSURANCE GROUP NO.

Registration --► Regular --► Patient secondary insurance screen’s <Group No>.

 

Box 62C    INSURANCE GROUP NO.

Registration --► Regular --► Patient tertiary (third) insurance screen’s <Group No>.

 

Box 63A    TREATMENT AUTHORIZATION CODES

 Charges --► Encounter --► UB-Encounter <Authorization No>.

 

Box 64A    DOCUMENT CONTROL NUMBER

Charges --► Encounter --► UB-Encounter <Internal Control>.

 

Boxes 63B through Box 64C

Not used.

 

Box 65A    EMPLOYER NAME

When the Registration --► Regular --► Patient primary insurance screen’s <Relation to Insured> is:

 

18: Registration --► Regular --► Patient  <Employer> prints.

 

Other than 18: Registration --► Regular --► Patient Insurance screen's <Insured’s Employer> prints.

 

 

Box 65B    EMPLOYER NAME

When the Registration --► Regular --► Patient secondary insurance screen’s <Relation to Insured> is:

 

18: Registration --► Regular --► Patient  <Employer> prints.

 

Other than 18: Registration --► Regular --► Patient  insurance screen's <Insured’s Employer> prints.


Box 65C    EMPLOYER NAME

When the Registration --► Regular --► Patient tertiary insurance screen’s <Relation to Insured> is:

 

18: Registration --► Regular --► Patient  <Employer> prints.

 

Other than 18: Registration --► Regular --► Patient  insurance screen's <Insured’s Employer> prints.

 

Box 66    DX Qualifier

Not currently used, but distinguishes between ICD-9 and ICD-10 coding.

 

Box 67      PRIN. DIAG. CD.

Charges --►Encounter --►UB-Encounter <Principal Diagnosis>.

 

837 Institutional Loop 2300 HI*BK

 

Box 67A    DX

Other Diagnoses Codes

 

Box 67B    DX

Other Diagnoses Codes

 

Box 67C    DX

Other Diagnoses Codes

 

Box 68      UNLABLED

Other Diagnoses Codes

 

Box 69      ADMIT DX CODE

The first diagnosis posted through Charges --►Charge.

 

Box 70 PATIENT REASON DX

Not Used

 

Box 71 PPS CODE

Not Used

 

Box 72 ECI CODE

Not Used

 

Box 73      UNLABLED

Not Used

 

Box 74      PRINCIPAL PROCEDURE CODE / DATE

Charges --► Encounter --► UB-Encounter <Principal Procedure> and <Date> .

 

Box 74a    OTHER PROCEDURE CODE / DATE

Charges --► Encounter --► UB-Encounter <Principal Procedure> and <Date> .

 

Box 74a    OTHER PROCEDURE CODE / DATE

Charges --► Encounter --► UB-Encounter <Principal Procedure> and <Date> .

 

Box 74b    OTHER PROCEDURE CODE / DATE

Charges --► Encounter --► UB-Encounter <Principal Procedure> and <Date> .

 

Box 74c     OTHER PROCEDURE CODE / DATE

Charges --► Encounter --► UB-Encounter <Principal Procedure> and <Date> .

 

Box 74d    OTHER PROCEDURE CODE / DATE

Charges --► Encounter --► UB-Encounter <Principal Procedure> and <Date> .

 

Box 74e    OTHER PROCEDURE CODE / DATE

Charges --► Encounter --► UB-Encounter <Principal Procedure> and <Date> .

 

Box 75      UNLABLED

Not Used.

 

Boxes 76 ATTENDING

Intellect prints the Referring physician information (Name and NPI) determined by the Utility --► Set Up --► Parameter <Referring> as completed at the time of posting. If a  referral is not posted in charges or entered in the Patient File, the treating doctor's referral information (Name and NPI) from Utility --►Referring is used:

 

P   Referring source originates from Registration --►Regular --►Patient <Referring Name>.

C   Referring source originates from that which was entered at the time of posting the charge through Charges --►Charge <Ref Prv>.

F   Referring source first originates from the charge screen Charges --►Charge <Ref Prv>. When not entered, it uses Registration --►Regular --►Patient <Referring Name>. 

 

NOTE: If the Utility/Referring Doctor/Other = O (other) the referring provider information does NOT print.

 

Last Name 837 Institutional Loop 2310A NM103

First Name 837 Institutional Loop 2310A NM104

NPI 837 Institutional Loop 2310A NM109

 

Box 77 OPERATING

Intellect prints the billing provider information as entered in Charges --►Charge <Billing Prv>.

 

The Utility --►Provider --►Provider-Facility <HCFA Box 24 J> number prints.

If a match is not found, the Utility --►Provider --►Provider-Provider <HCFA Box 24 J> number prints. If a match is not found, the Utility --►Provider <HCFA Box 24J 1>, <HCFA Box 24J 2> or <HCFA Box 24J 3> prints, depending on Utility --► Insurance --► Insurance <Selection 1/2/3>

 

Boxes 78     OTHER

Not used.

 

Boxes 79     OTHER

Not used.

 

Boxes 80a through c     REMARKS

Prints the Charges --►Encounter --►UB Encounter <Claim Notes>.

 

837 Institutional Loop 2300 NTE 02

 

Effective version 9.12.29, for all Worker's Compensation patients, per the client’s request, the address where the employee works, as shown in the <Address> field of the Registration --►Worker --►Worker Insurance screen, can be added. This change is not automatically added with the update. To have this change, call Prime Clinical Systems and request the form update.

 

Box 81CC     

81CC a – 1st box Utility --► Referring <Taxonomy> preceded by a B3 qualifier

81CC b – 1st box Utility --► Referring <Taxonomy> preceded by a B3 qualifier

 

Effective version 9.12.29, for all Worker's Compensation patients, the third part of Box 81 prints: <REPORT_TYPE_CODE> + <REPORT_TRANSMISSION_CODE> + <IDENTIFICATION_CODE> from the Charges --►Encounter --►Generic screen.

 

When the report type is blank, then the third part of Box 81 is blank. The WC Claims now require the Report Type, Report Transmission, and Identification. If they are completed in the Encounter screen, the values entered print here.

 

The changes to UB04 forms are not automatically added with the 9.12.29 update. To have this change, call Prime Clinical systems and request the form update.

 

NOTE:  Electronic claims submission always submits detailed charge information –regardless of paper claim billing requirements.

 

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