Outpatient by gi96f4T

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									Create a FIXED FORMAT ASCII text file for each patient record. Be careful to SPACE FILL where indicated. When subm

Encryption software can be found at: http://www.unlv.edu/Research_Centers/chia/hospitalinpatientdata/html/chiacryptor.h
NOTE: The Form Locators (FL##) are based on the UB04. It is understood that ASC's typically do not use UB04 forms, but base
ASCs. If a UB04 manual is needed (for fields not included in the Field Definitions tab) it can be obtained from: http://nvha.net/w

                   Data Element                        Starting Group    Group      Number of
                                                       Position Length   Repeat     Characters

Provider Name                                             1                             25

Provider Address                                         26                             25

Provider City                                            51                             12

Provider State                                           63                              2

Provider Zip Code                                        65                             10

Provider Telephone Number                                75                             12

Provider Fax Number                                      87                             12

Provider Country Code                                    99                              2

Pay-to Name                                              101                            25

Pay-to Address                                           126                            25

Pay-to City                                              151                            16

Pay-to State                                             167                             2

Pay-to Zip                                               169                             5

Reserved FL02                                            174                            25

Patient Control Number                                   199                            20

Medical/Health Record Number                             219                            24

Type of Bill (First three digits including preceding     243                             3
zero)
Type of Bill Frequency Code                              246                             1
(Last alphanumeric)
Federal Tax Number (Upper line)                          247                             4

Federal Tax Number (Lower line)                          251                            10

Statement Covers Period (From)                           261                            10
Statement Covers Period (Through)      271   10




Reserved FL07A                         281   7

Reserved FL07B                         288   8

Patient Identifier                     296   19

Patient Social Security Number         315   9

Patient Name                           324   29

Patient Street Address                 353   40

Patient City                           393   30

Patient State                          423   2

Patient Zip                            425   9


Patient Country Code                   434   2

Patient Birth Date                     436   10


Patient Gender                         446   1

Patient Marital Status                 447   1



Patient Race                           448   1


Admission (Visit)/Start of Care Date   449   10



Admission (Visit) Hour                 459   2

AdmissionType                          461   1

Referral Source                        462   1

Discharge Hour                         463   2

Discharge Status                       465   2
Condition Codes                  467    22     11   2



Accident State                   489                2

Reserved FL30A                   491                11

Reserved FL30B                   502                13

Occurrence Code                  515    96     8    2

Occurrence Date                                     10

Occurrence Span Code             611    88     4    2

Occurrence Span Date From                           10

Occurrence Span Date Through                        10

Reserved FL37                    699                8

Responsible Party Name/Address   707    200    5    40

Value Code                       907    44     4    2

Value Code Amount                                   9



Value Code                       951    44     4    2

Value Code Amount                                   9


Value Code                       995    44     4    2

Value Code Amount                                   9

Revenue Code                     1039   1738   22   4




Revenue Code Description                            24
Rate Codes                                     14




Service Date (visit)                           10



Service Units                                  7




Total Charges - Dollars                        7

Total Charges - Cents                          2


Non-covered Charges - Dollars                  7

Non-covered Charges - Cents                    2

Reserved FL49                                  2

Revenue Code                            2777   4



Summary Total Charges - Dollars         2781   7


Summary Total Charges - Cents           2788   2

Summary Non-covered Charges - Dollars   2790   7

Summary Non-covered Charges - Cents     2797   2

Reserved 49L23                          2799   2
Current Page                      2801   3




Total Pages                       2804   3




Creation Date                     2807   10

Payer Name - Primary              2817   23

Payer Name - Secondary            2840   23



Payer Name - Tertiary             2863   23


Health Plan ID A                  2886   15

Health Plan ID B                  2901   15


Health Plan ID C                  2916   15


Information Release - Primary     2931   1

Information Release - Secondary   2932   1

Information Release - Tertiary    2933   1

Benefits Assignment - Primary     2934   1
Benefits Assignment - Secondary            2935   1

Benefits Assignment - Tertiary             2936   1

Prior Payments Dollars - Primary           2937   7



Prior Payments Cents - Primary             2944   2

Prior Payments Dollars - Secondary         2946   7



Prior Payments Cents - Secondary           2953   2

Prior Payments Dollars - Tertiary          2955   7



Prior Payments Cents - Tertiary            2962   2

Estimated Amount Due Dollars - Primary     2964   7


Estimated Amount Due Cents - Primary       2971   2

Estimated Amount Due Dollars - Secondary   2973   7


Estimated Amount Due Cents - Secondary     2980   2

Estimated Amount Due Dollars - Tertiary    2982   7


Estimated Amount Due Cents - Tertiary      2989   2

National Provider Identifier(NPI)          2991   15




Other Provider - Primary                   3006   15
Other Provider - Secondary                    3021   15




Other Provider - Tertiary                     3036   15




Insured Name - Primary                        3051   25

Insured Name - Secondary                      3076   25




Insured Name - Tertiary                       3101   25




Patient Relationship To Insured - Primary     3126   2

Patient Relationship To Insured - Secondary   3128   2


Patient Relationship To Insured - Tertiary    3130   2


Insured Unique ID - Primary                   3132   20

Insured Unique ID - Secondary                 3152   20

Insured Unique ID - Tertiary                  3172   20
Insured Group Name - Primary                  3192   14

Insured Group Name - Secondary                3206   14




Insured Group Name - Tertiary                 3220   14




Insured Group Number - Primary                3234   17
Insured Group Number - Secondary           3251   17




Insured Group Number - Tertiary            3268   17




Treatment Authorization Code - Primary     3285   30




Treatment Authorization Code - Secondary   3315   30

Treatment Authorization Code - Tertiary    3345   30

Document Control Number - A                3375   26




Document Control Number - B                3401   26

Document Control Number - C                3427   26

Employer Name - Primary                    3453   25
Employer Name - Secondary                  3478   25

Employer Name - Tertiary                   3503   25

ICD Version Indicator                      3528   1

Principal Diagnosis Code                   3529   8
Other Diagnosis - A        3537   8




Other Diagnosis - B        3545   8

Other Diagnosis - C        3553   8

Other Diagnosis - D        3561   8

Other Diagnosis - E        3569   8

Other Diagnosis - F        3577   8

Other Diagnosis - G        3585   8

Other Diagnosis - H        3593   8

Other Diagnosis - I        3601   8

Other Diagnosis - J        3609   8

Other Diagnosis - K        3617   8

Other Diagnosis - L        3625   8

Other Diagnosis - M        3633   8

Other Diagnosis - N        3641   8

Other Diagnosis - O        3649   8

Other Diagnosis - P        3657   8

Other Diagnosis - Q        3665   8

Reserved - 68A             3673   8

Reserved - 68B             3681   9

Admitting Diagnosis Code   3690   7

Patient Visit Reason - A   3697   7

Patient Visit Reason - B   3704   7
Patient Visit Reason - C            3711   7




PPS Code                            3718   4




External Cause of Injury Code - A   3722   8




External Cause of Injury Code - B   3730   8

External Cause of Injury Code - C   3738   8

Reserved FL73                       3746   1

Procedure Code - Principal          3747    7
Procedure Date - Principal          3754   10

Procedure Code - Other A            3764    7
Procedure Date - Other A            3771   10

Procedure Code - Other B            3781   7

Procedure Date - Other B            3788   10

Procedure Code - Other C            3798   7

Procedure Date - Other C            3805   10

Procedure Code - Other D            3815   7

Procedure Date - Other D            3822   10

Procedure Code - Other E            3832   7

Procedure Date - Other E            3839   10

Reserved FL75A                      3849   4

Reserved FL75B                      3853   4

Reserved FL75C                      3857   4

Reserved FL75D                      3861   4
Attending NPI     3865   11

Attending QUAL    3876   2




Attending ID      3878   9


Attending Last    3887   16



Attending First   3903   12

Operating NPI     3915   11

Operating QUAL    3926   2




Operating ID      3928   9


Operating Last    3937   16

Operating First   3953   12

Other NPI - A     3965   11

Other QUAL - A    3976   2




Other ID - A      3978   9


Other Last - A    3987   16

Other First - A   4003   12

Other NPI - B     4015   11

Other QUAL - B    4026   2

Other ID - B      4028   9
Other Last - B             4037   16

Other First - B            4053   12

Payer Code A - Primary     4065   2




Payer Code B - Secondary   4067   2

Payer Code C - Tertiary    4069   2

Remarks - 1                4071   19




Remarks - 2                4090   24

Remarks - 3                4114   24

Remarks - 4                4138   24

Code-Code-QUAL - A         4162   2

Code-Code-CODE - A         4164   10

Code-Code-VALUE - A        4174   12

Code-Code-QUAL - B         4186   2

Code-Code-CODE - B         4188   10

Code-Code-VALUE - B        4198   12

Code-Code-QUAL - C         4210   2

Code-Code-CODE - C         4212   10

Code-Code-VALUE - C        4222   12

Code-Code-QUAL - D         4234   2

Code-Code-CODE - D         4236   10

Code-Code-VALUE - D        4246   12
Total line length   4257
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C's typically do not use UB04 forms, but based on ASC surveys, the code definitions match those used by
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                             Field Attributes             Field Requirement? (see Field          NUBC
                                                          Definitions tab for additional         Form
                                                          information.)                         Locator
            Alphanumeric                                  Required                                FL01
            Left Justified
            Alphanumeric                                  Required                                FL01
            Left Justified
            Alphanumeric                                  Required                                FL01
            Left Justified
            Alphanumeric                                  Required                                FL01
            Left Justified
            Alphanumeric                                  Required                                FL01
            Left Justified 89523-5058
            Alphanumeric                                  When Available                          FL01
            Left Justified 999-999-9999
            Alphanumeric                                  When Available                          FL01
            Left Justified 999-999-9999
            Alphanumeric                                  Required when address is outside        FL01
            Left Justified                                of the United States
            Alphanumeric                                  Required when address for               FL02
            Left Justified                                payment is different than FL01
            Alphanumeric                                  Required when address for               FL02
            Left Justified                                payment is different than FL01
            Alphanumeric                                  Required when address for               FL02
            Left Justified                                payment is different than FL01
            Alphanumeric                                  Required when address for               FL02
            Left Justified                                payment is different than FL01
            Alphanumeric                                  Required when address for               FL02
            Left Justified 89523                          payment is different than FL01
            Space filled                                  Space filled                            FL02

            Alphanumeric                                  Required                               FL03a
            Left Justified
            Space filled                                  Space filled                           FL03b

            Alphanumeric                                  Required                                FL04
            Left Justified
            Alphanumeric                                  Required                                FL04
            Left Justified
            Alphanumeric                                  Optional                                FL05
            Left Justified
            Alphanumeric                                  Required                                FL05
            Left Justified. Format: 99-9999999
            Date                                          Required                                FL06
            MM/DD/YYYY
Date                                        Optional                                FL06
MM/DD/YYYY




Space filled                                Space filled                            FL07A

Space filled                                Space filled                            FL07B

Space filled                                Space filled                            FL08a

Space filled                                Space filled

Space filled                                Space filled                            FL08b

Space filled                                Space filled                            FL09a

Alphanumeric                                Required                                FL09b
Left Justified
Alphanumeric                                Required                                FL09c
Left Justified
Numeric                                     Required                                FL09d
Left Justified 999999999
Spaced filled = Unknown
Alphanumeric                                If outside the U.S.                     FL09e
Left Justified. Part I of ISO 3166
Date                                        Required.                               FL10
MM/DD/YYYY
00/00/0000 = Unknown
Alphanumeric                                Required                                FL11
(M)ale, (F)emale, (U)nknown
Alphanumeric                                If Available                            FL81
1=Single, 2=Married, 3=Life Partner,
4=Legally Separated, 5=Divorced, 6=Widow,
9=Unknown
1=Native American/Alaskan, 2=Asian.         If Available
Pacific Islander. 3=Black, 4=White,
5=Hispanic, 6=Other, 9=Unknown
Date                                        Optional - If used, it is the same as   FL12
MM/DD/YYYY                                  the STATEMENT COVERS
                                            PERIOD FROM DATE (FL06)
Alphanumeric                                If Available                            FL13
00 through 23 (00 being midnight)
Space filled                                Space filled                            FL14

Space filled                                Space filled                            FL15

Alphanumeric                                If Available                            FL16
00 through 23 (00 being midnight)
Space filled                                Space filled                            FL17
Alphanumeric                                      Required when there is a condition      FL18-28
Left Justified (See Code Book)                    code relating to this claim (see
                                                  pages 52-64 of UB04 Manual)
Alphanumeric                                      Only for auto accidents - Ecodes         FL29
Left Justified                                    (E810-E819)
Space filled                                      Space filled                            FL30A

Space filled                                      Space filled                            FL30B

Alphanumeric                                      When there is an Occurrence Code        FL31-34
Left Justified (See Code Book)                    that applies to this claim (see pages
Date                                              67-74 of UB04 Manual)
MM/DD/YYYY
Alphanumeric                                      When there is an Occurrence Span        FL35-36
Left Justified (See Code Book)                    Code that applies to this claim (see
Date                                              pages 75-78 of the UB04 Manual)
MM/DD/YYYY
Date
MM/DD/YYYY
Space filled                                      Space filled                             FL37

Space filled                                      Space filled                             FL38

Alphanumeric                                      Required when there is a value           FL39
Left Justified. All positions fully Coded         code that applies to this claim. (see
Numeric                                           pages 81-97 of UB-04
Right Justified, Negative numbers are not         Specifications Manual)
allowed except in FL41.
Alphanumeric                                      Required when there is a value           FL40
Left Justified. All positions fully Coded         code that applies to this claim. (See
Numeric                                           UB-04 Specifications Manual)
Right Justified, Negative numbers are not
allowed except in FL41.
Alphanumeric                                      Required when there is a value           FL41
Left Justified. All positions fully Coded         code that applies to this claim. (See
Numeric                                           UB-04 Specifications Manual)
Right Justified, '-' prefix allowed.
Alphanumeric                                      Required (see pages 98-156 of UB-        FL42
Left Justified. All positions fully Coded. Last   04 Specifications Manual)
position must be a numeric 0-9 denoting
subcategory.Listed in Ascending numeric
order, by date of Service. (See Code Book)
Alphanumeric                                      Optional                                 FL43
Left Justified
Alphanumeric                                   Required when there is a procedure       FL44
Format Depends on bill type. (See Code         - (CPT Codes) - The Healthcare
Book)                                          Common Procedure Coding
left-justified for HCPCS and HIPPS Rate        System (HCPCS) applicable to
Codes.                                         ancillary service and outpatient
                                               bills.HCPCS and HIPPS Rate
                                               Codes Situational: Required for
                                               outpatient claims when an
                                               appropriate HCPCS or HIPPS code
                                               exists for this service line item.
The date the outpatient service was provided Required (it is possible for this date     FL45
                            Date Format:     to differ from the STATEMENT
MM/DD/YYYY                                   COVERS PERIOD FROM date.

Numeric                                        Required                                 FL46
Right Justified                                When (CPT) codes are reported,
                                               the unit is defined by the HCPCS
                                               definition. Where the unit is not
                                               defined by the HCPCS code, units
                                               can be reported as “1” or more
                                               based on the provider’s practice,
                                               health plan requirements or
                                               regulation. A zero or negative value
                                               is not allowed.

Numeric                                                                                 FL47
Right Justified. No decimals
Numeric                                                                                 FL47
Right Justified. No decimals

Numeric                                                                                 FL48
Right Justified. No decimals
Numeric                                        National Uniform Billing Committee       FL48
Right Justified. No decimals                   Official UB-04 Data Specifications
Space filled                                   Space 2009
                                               Manualfilled                             FL49

Alphanumeric                                   Required on Patients last line of the   FL42L23
Left Justified. '0001' to signify total.       format file. See FL43L23. Space fill
                                               on lines preceding total line.
Numeric                                        Required on Patients last line of the   FL47L23
Right Justified.                               format file. See FL43L23. Space fill
                                               on lines preceding total line.
                                                                                       FL47L23

                                               When FL48 has been populated,           FL48L23
                                               required on Patients last line of the
                                               format file. See FL43L23. Space fill    FL48L23
                                               on lines preceding total line.
Space filled                                   Space filled                            FL49L23
Numeric                                         Required                            FL43L23
Left Justified.
Special Note: A page equals 1 line in the
submission data file. If additional lines (more
than 22 revenue codes, for example) are
needed, do not duplicate the entire record.
Repeat only the Provider Name-FL01,
Patient Control Number- FL03a, and then
any continuation of unduplicated data
(revenue codes 23 through 40, for example).
Both Diagnosis codes and Procedure codes
are also likely fields to require many lines in
the submission data file. All Revenue
codes, Diagnosis Codes, and Procedure
codes must be present in the submission
data file for a given patient.
     NOTE: Continuation lines are in the
same format as primary lines, the only
difference being most of the fields are left
blank. The continuation fields are also in the
same column positions as in the primary line.
Numeric                                       Required                              FL44L23
Left Justified.
Total number of lines for this Patient record
in the format file. See Current Page FL43L23

Date                                          If Available                          FL45L23
MM/DD/YYYY
Alphanumeric                                  Required (self pay can say either     FL50A
Left Justified                                Self Pay or be left blank)
Alphanumeric                                  Situational. Required when other      FL50B
Left Justified                                payers are known to potentially be
                                              involved in paying this claim
Alphanumeric                                  Situational. Required when other      FL50C
Left Justified                                payers are known to potentially be
                                              involved in paying this claim
Alphanumeric                                  If Available (can be blank for self   FL51A
Left Justified                                pay)
Alphanumeric                                  Situational. Required when other      FL51B
Left Justified                                payers are known to potentially be
                                              involved in paying this claim
Alphanumeric                                  Situational. Required when other      FL51C
Left Justified                                payers are known to potentially be
                                              involved in paying this claim
Alphanumeric                                  Required                               FL52

Alphanumeric                                  Situational                            FL52

Alphanumeric                                  Situational                            FL52

Alphanumeric                                  Required                               FL53
Alphanumeric      Situational                             FL53

Alphanumeric      Situational                             FL53

Numeric           Situational. Required when the          FL54
Right Justified   indicated payer has paid an amount
                  to the provider towards this bill

Numeric                                                   FL54
Right Justified
Numeric           Situational. Required when the          FL54
Right Justified   indicated payer has paid an amount
                  to the provider towards this bill

Numeric                                                   FL54
Right Justified
Numeric           Situational. Required when the          FL54
Right Justified   indicated payer has paid an amount
                  to the provider towards this bill

Numeric                                                   FL54
Right Justified
Numeric           Situational. Required when the          FL55
Right Justified   provider estimates an amount due
                  from the indicated payer
Numeric                                                   FL55
Right Justified
Numeric           Situational. Required when the          FL55
Right Justified   provider estimates an amount due
                  from the indicated payer
Numeric                                                   FL55
Right Justified
Numeric           Situational. Required when the          FL55
Right Justified   provider estimates an amount due
                  from the indicated payer
Numeric                                                   FL55
Right Justified
Alphanumeric      Situational: Required for all           FL56
Left Justified    providers in the United States or its
                  territories when the provider is
                  eligible for an NPI.



Alphanumeric      Situational. Required prior to the      FL57
Left Justified    mandated NPI Implementation
                  Date or when an additional
                  identification number is necessary
                  for the receiver to identify the
                  provider
Alphanumeric     Situational. Required prior to the    FL57
Left Justified   mandated NPI Implementation
                 Date or when an additional
                 identification number is necessary
                 for the receiver to identify the
                 provider
Alphanumeric     Situational. Required prior to the    FL57
Left Justified   mandated NPI Implementation
                 Date or when an additional
                 identification number is necessary
                 for the receiver to identify the
                 provider
Space filled     Space filled                          FL58

Space filled     Space filled                          FL58




Space filled     Space filled                          FL58




Alphanumeric     If Available                          FL59
Left Justified
Alphanumeric     If Available                          FL59
Left Justified

Alphanumeric     If Available                          FL59
Left Justified

Space filled     Space filled                          FL60

Space filled     Space filled                          FL60

Space filled     Space filled                          FL60
Alphanumeric     Situational. Required if available    FL61
Left Justified   and FL62 is not used
Alphanumeric     Situational. Required when other      FL61
Left Justified   insurance/ payers/health plans are
                 known to potentially be involved in
                 paying this claim and when FL62 B
                 and C are not used
Alphanumeric     Situational. Required when other      FL61
Left Justified   insurance/ payers/health plans are
                 known to potentially be involved in
                 paying this claim and when FL62 B
                 and C are not used
Alphanumeric     Situational. Required when the        FL62
Left Justified   insured's identification card shows
                 a group number
Alphanumeric                                     Situational. Required when other        FL62
Left Justified                                   insurance/ payers/health plans are
                                                 known to potentially be involved in
                                                 paying this claim and when the
                                                 other insurance's identification card
                                                 shows a group number
Alphanumeric                                     Situational. Required when other        FL62
Left Justified                                   insurance/ payers/health plans are
                                                 known to potentially be involved in
                                                 paying this claim and when the
                                                 other insurance's identification card
                                                 shows a group number
Alphanumeric                                     Situational. Required when an           FL63
Left Justified                                   authorization number is assigned
                                                 by te payer or UMO (Utilization
                                                 Management Organization) and the
                                                 services on this claim were
                                                 preauthorized
Alphanumeric                                     See FL63 primary                        FL63
Left Justified
Alphanumeric                                     See FL63 primary                        FL63
Left Justified
Alphanumeric                                     Situational. Required when type of      FL64
Left Justified                                   Bill Frequency Code (FL04)
                                                 indicates this claim is a
                                                 replacement or void to a previously
                                                 adjudicated claim. Payer A should
                                                 be listed on Document Control
                                                 Number A
Alphanumeric                                     See FL64 A                              FL64
Left Justified
Alphanumeric                                     See FL64 A                              FL64
Left Justified
Blank out by filling with space characters       Space filled                            FL65
Space filled                                     Space filled                            FL65

Space filled                                     Space filled                            FL65

Alphanumeric (9=ICD9, 0= ICD10)                  Required                                FL66

Alphanumeric                                     Principal Diagnosis Code is             FL67
Left Justified. No decimals. Position 8 is the   Required.
"Present on Admission" indicator. It may
contain one of the following:                    Present on Admission (POA) is
"Y" = Yes.                                       only required for inpatient
"N" = No.                                        records (not outpatient)
"U" = No information in the Record.
"W" = Clinically Undetermined.                   See the National Uniform Billing
"1" = Exempt.                                    Committee Official UB-04 data
                                                 specifications Manual for reporting
Include "V" codes (Follow the official coding    requirements.
guidelines for ICD reporting)
Alphanumeric                             Situational. Required when other        FL67A
See FL67 Principal Diagnosis for usage   conditions coexist or develop
                                         subsequently during the patient's
                                         treatment.

Alphanumeric                             See FL67 A                              FL67B
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67C
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67D
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67E
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67F
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67G
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67H
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67I
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67J
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67K
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67L
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67M
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67N
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67O
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67P
See FL67 Principal Diagnosis for usage
Alphanumeric                             See FL67 A                              FL67Q
See FL67 Principal Diagnosis for usage
Space filled                                                                     FL68A

Space filled                                                                     FL68B

Alphanumeric                             Situational. Required when claim        FL69
Left Justified                           involves an inpatient admission.
Alphanumeric                             Situational.                            FL70
Left Justified                           1. Required when available for all
Alphanumeric                             unscheduled outpatient visits. An       FL70
Left Justified                           “unscheduled” outpatient visit is
                                         defined as an outpatient Type of Bill
                                         013X or 085X, together with Form
                                         Locator 14 (Priority of Visit/Type of
                                         Admission) codes 1, 2 or 5 and
                                         Revenue Codes 045X, 0516,
                                         0526, or 0762 (Observation Room).
                                             Situational.
                                             1. Required when available for all
                                             unscheduled outpatient visits. An
                                             “unscheduled” outpatient visit is
Alphanumeric                                 defined as an outpatient Type of Bill   FL70
Left Justified                               013X or 085X, together with Form
                                             Locator 14 (Priority of Visit/Type of
                                             Admission) codes 1, 2 or 5 and
                                             Revenue Codes 045X, 0516,
                                             0526, or 0762 (Observation Room).


Numeric                                      Situational. Optional for inpatient     FL71
Right Justified. All positions fully coded   claims when the hospital is under
                                             contract with the health plan to
                                             provide this information (NOT
                                             REQUIRED FOR OUTPATIENT.)
Alphanumeric                                 Situational. Required when an           FL72
Left Justified                               injury, poisoning, or adverse effect
                                             is the cause for seeking medical
                                             treatment or occurs during the
                                             medical treatment.
Alphanumeric                                 Situational                             FL72
Left Justified
Alphanumeric                                 Situational                             FL72
Left Justified
Space filled                                 Space filled                            FL73

Space filled                                 Space filled                            FL74
Space filled                                 Space filled                            FL74

Space filled                                 Space filled                            FL74
Space filled                                 Space filled                            FL74

Space filled                                 Space filled                            FL74

Space filled                                 Space filled                            FL74

Space filled                                 Space filled                            FL74

Space filled                                 Space filled                            FL74

Space filled                                 Space filled                            FL74

Space filled                                 Space filled                            FL74

Space filled                                 Space filled                            FL74

Space filled                                 Space filled                            FL74

Space filled                                 Space filled                            FL75A

Space filled                                 Space filled                            FL75B

Space filled                                 Space filled                            FL75C

Space filled                                 Space filled                            FL75D
Alphanumeric                             Required when the provider has an      FL76
Left Justified                           NPI
Alphanumeric                             Situational: Required if there is no   FL76
Left Justified                           NPI. Order of preference for these
"0B" = State License Number       "1G"   codes is 1) UPIN, 2) State License
= Physician UPIN number,      "G2" =     Number, 3) Provider Commercial
Provider Commercial
Alphanumeric                             Situational: Required if there is no   FL76
Left Justified                           NPI.
Alphanumeric                             Situational. Required when the         FL76
Left Justified                           claim contains any services other
                                         than non-scheduled transportation
                                         claims
Alphanumeric                             See FL76 Attending Last                FL76
Left Justified
Alphanumeric                             Situational: Required When             FL77
Left Justified                           Available. See FL76.
Alphanumeric                             Situational: Required when             FL77
Left Justified                           available and if there is no NPI.
"0B" = State License Number       "1G"   Order of preference for these codes
= Physician UPIN number,      "G2" =     is 1) UPIN, 2) State License
Provider Commercial                      Number, 3) Provider Commercial

Alphanumeric                             Situational: Required when             FL77
Left Justified                           available and if there is no NPI.
Alphanumeric                             Situational: Required When             FL77
Left Justified                           Available. See FL76.
Alphanumeric                             Situational: Required When             FL77
Left Justified                           Available. See FL76.
Alphanumeric                             Situational: Required When             FL78
Left Justified                           Available. See FL76.
Alphanumeric                             Situational: Required when             FL78
Left Justified                           available and if there is no NPI.
                                         Order of preference for these codes
                                         is 1) UPIN, 2) State License
                                         Number, 3) Provider Commercial




Alphanumeric                             Situational: Required when             FL78
Left Justified                           available and if there is no Other
                                         NPI.
Alphanumeric                             Situational: Required When             FL78
Left Justified                           Available. See FL76.
Alphanumeric                             Situational: Required When             FL78
Left Justified                           Available. See FL76.
Alphanumeric                             Situational: Required When             FL79
Left Justified                           Available. See FL76.
Alphanumeric                             Situational: Required When             FL79
Left Justified                           Available. See FL76.
Alphanumeric                             Situational: Required When             FL79
Left Justified                           Available. See FL76.
Alphanumeric      Situational: Required When             FL79
Left Justified    Available. See FL76.
Alphanumeric      Situational: Required When             FL79
Left Justified    Available. See FL76.
Alphanumeric      Required (definitions for valid
Left Justified    codes can be found at the
                  bottom of the Field Definitions
                  page.)
Alphanumeric      Required when available
Left Justified
Alphanumeric      Required when available
Left Justified
Alphanumeric      Situational. Required when in the      FL80
Left Justified    judgment of the provider, the
                  information is needed to sustantiate
                  the medical treatment and is not
                  supported elsewhere within the
                  claim data set.

Alphanumeric      Situational.                           FL80
Left Justified
Alphanumeric      Situational.                           FL80
Left Justified
Alphanumeric      Situational.                           FL80
Left Justified
Alphanumeric      Situational.                           FL81A
Left Justified
Alphanumeric      Situational.                           FL81A
Left Justified
Numeric           Situational.                           FL81A
Right Justified
Alphanumeric      Situational.                           FL81B
Left Justified
Alphanumeric      Situational.                           FL81B
Left Justified
Numeric           Situational.                           FL81B
Right Justified
Alphanumeric      Situational.                           FL81C
Left Justified
Alphanumeric      Situational.                           FL81C
Left Justified
Numeric           Situational.                           FL81C
Right Justified
Alphanumeric      Situational.                           FL81D
Left Justified
Alphanumeric      Situational.                           FL81D
Left Justified
Numeric           Situational.                           FL81D
Right Justified
                                             NEVADA HOSPITAL DISCHARGE REPORTING - FIELD DEFINITION




   NUBC                             Data Element                                                                         Definition
   Form
  Locator
FL01            Provider Name                                           Provider submitting the Bill
FL01            Provider Address                                        Service location Address
FL01            Provider City                                           Service location City
FL01            Provider State                                          Service location State
FL01            Provider Zip Code                                       Service location Zip Code
FL01            Provider Telephone Number                               Service location Telephone Number
FL01            Provider Fax Number                                     Service location Fax Number
FL01            Provider Country Code                                   Service location Country Code
FL02            Pay-to Name                                             The name and address that the provider submitting the bill intends payment to be sent if different from
FL02            Pay-to Address                                          FL01.
FL02            Pay-to City
FL02            Pay-to State
FL02            Pay-to Zip
FL02            Reserved                                                Fill with spaces
FL03a           Patient Control Number                                  Patient's unique number assigned by the provider
FL03b           Medical/Health Record Number                            Number assigned to patient's records by provider (Fill with spaces)
FL04            Type of Bill (First three digits)                       Specifies In/outpatient
                Type of Bill Frequency Code (Last alphanumeric)         Forth digit of Type of Bill Field (see below for details)
Bill Type       Use                                                     Description
0000-010X       RSVRD                                                   Reserved for Assignment by NUBC
011x            IP                                                      Hospital Inpatient (Including Medicare Part A)
012X            IP/OP                                                   Hospital Inpatient (Medicare Part B only)
013X            OP                                                      Hospital Outpatient
014X            OP                                                      Hospital - Laboratory Services Provided to Non-patients
015-017X        RSRVD                                                   Reserved for Assignment by NUBC
018X            IP                                                      Hospital - Swing Beds
019-020X        RSRVD                                                   Reserved for Assignment by NUBC
021X            IP                                                      Skilled Nursing - Inpatient (Including Medicare Part A)
022X            IP/OP                                                   Skilled Nursing - Inpatient (Medicare Part B only)
023X            OP                                                      Skilled Nursing - Outpatient
024-027X        RSVRD                                                   Reserved for Assignment by NUBC
028X            IP                                                      Skilled Nursing - Swing Beds
029-031X        RSVRD                                                   Reserved for Assignment by NUBC
032X            IP/OP                                                   Home Health - Inpatient (plan of treatment under Part B only)
033X            OP                                                      Home Health - Outpatient (plan of treatment under Part A, including DME under Part A)
034X            OP                                                      Home Health - Other (for medical and surgical services not under plan of treatment)
035-040X        RSVRD                                                   Reserved for Assignment by NUBC
041X            IP                                                      Religious Non-Medical Health Care Institutions - Hospital Inpatient
042X            RSVRD                                                   Reserved for Assignment by NUBC
043X            OP                                                      Religious Non-Medical Health Care Institutions - Outpatient Services
044-064X        RSVRD                                                   Reserved for Assignment by NUBC
065X            IP                                                      Intermediate Care - Level I
066X            IP                                                      Intermediate Care - Level II
067-070X        RSVRD                                                   Reserved for Assignment by NUBC
071X            OP                                                      Clinic - Rural Health
072X            OP                                                      Clinic - Hospital Based or Independent Renal Dialysis Center
073X            OP                                                      Clinic - Freestanding
074X            OP                                                      Clinic - Outpatient Rehabilitation Facility (ORF)
075X            OP                                                      Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
076X            OP                                                      Clinic - Community Mental Health Center OP
077-078X        RSVRD                                                   Reserved for Assignment by NUBC
079X            OP                                                      Clinic - Other
080X            RSVRD                                                   Reserved for Assignment by NUBC
081X            OP                                                      Special Facility - Hospice (non-hospital based)
082X            OP                                                      Special Facility - Hospice (hospital based)
083X            OP                                                      Special Facility - Ambulatory Surgery Center
084X            IP                                                      Special Facility - Free Standing Birthing Center
085X            OP                                                      Special Facility - Critical Access Hospital
086X            IP                                                      Special Facility - Residential Facility
087-088X        RSVRD                                                   Reserved for Assignment by NUBC
089X            IP/OP                                                   Special Facility - Other IP or OP
090X-9999       RSVRD                                                   Reserved for Assignment by NUBC

FL04            Type of Bill Frequency Codes:
Frequency       Use                                                     Description
            0   Non-Payment/Zero                                        When provider has non-reimbursable items and does not anticipate payment.
            1   Admit Through Discharge Claim                           Inpatient records only - A complete bill for a specific period.
            2   Interim - First Claim                                   Inpatient records only - First of a series of bill to the same third party for the same patient.
            3   Interim - Continuing Claim (b)                          Inpatient records only - Subsequent bills to the same third party for the same patient.
            4   Interim - Last Claim (b)                                Inpatient records only - Final bill to the same third party for the same patient.
            5   Late Charge(s) Only                                     Inpatient records only - Use this code if submitting charges after the final bill.
            6   Reserved
            7   Replacement of Prior Claim (a)                          Use when original bill was in error and was voided.
            8   Void/Cancel of Prior Claim (a)                          This voids a bill and should contain the same information as the original bill.


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                                              NEVADA HOSPITAL DISCHARGE REPORTING - FIELD DEFINITION




  NUBC                               Data Element                                                                       Definition
  Form
 Locator
           9    Final Claim for a Home Health PPS Episode                Specific to Home Health - Contains debit or credit for initial home health bill.
           A    Admission/Election Notice                                Used when non-Medical Health Care institution is submitting bill as an admission or election notice.
           B    Hospice/CMS Coordinated Care/non-Medical…                Termination or revocation of institution election.
           C    Hospice Change of Provider Notice                        Used as notice of hospice provider.
           D    Hospice/CMS Coordinated Care/non-Medical…(void)          Notice of Void/Cancel of provider
           E    Hospice Change of Ownership                              Notice of change in ownership of hospice.
           F    Beneficiary Initiated Adjustment Claim                   Use to identify adjustments initiated by the beneficiary.
           G    CWF Initiated Adjustment Claim                           Use to identify adjustments initiated by the CWF.
           H    CMS Initiated Adjustment                                 Use to identify adjustments initiated by the CMS.
            I   Intermediary Adjustment Claim                            Use to identify adjustments initiated by the intermediary.
           J    Initiated Adjustment Claim - Other                       Use to identify adjustments initiated by the other entity.
           K    OIG Initiated Adjustment Claim                           Use to identify adjustments initiated by the OIG.
           L    Reserved
           M    MSP Initiated Adjustment Claim                           Use to identify adjustments initiated by the MSP.
           N    Reserved
           O    Nonpayment/Zero Claims                                   Inpatient records only - non-payment bill.
           P    QIO Adjustment Claim                                     Adjustment initiated by QIO review.
                Claim Submitted for Reconsideration Outside of Timely
          Q     Limits                                                   This code is for internal payer use only - not to be used by providers.
        R-W     Reserved
          X     Void/Cancel a Prior Abbreviated Encounter Submission     Used by a Medicare Advantage contractor or other plan to void an incorrect bill.
                Replacement of Prior Abbreviated Encounter
           Y    Submission                                               Used by a Medicare Advantage contractor or other plan to replace an incorrect bill.
           Z    New Abbreviated Encounter Submission                     Used by a Medicare Advantage contractor or other plan to submit a new bill.

              The developers of the Professional and Dental Health
              Care Claim Implementation Guides (ASC X12N 837
          (a) (004010X098, 004010X097, 005010X222 and
              005010X224)) have indicated that this code is
              acceptable for use in those transactions.

              Do not use for Medicare PPS claims. (For second and
          (b) subsequent interim bills use code 7, and see Condition
              Code D3 (FL18-FL28).


FL05            Federal Tax Number (Upper line)                          Federal Tax sub-ID number assigned by the provider and is used by provider to assign a unique
                                                                         number to their affiliated subsidiaries
FL05            Federal Tax Number (Lower line) (Include Hyphen)         Federal Tax number assigned by Federal Government
FL06            Statement Covers Period (From)                           Not to be confused with Admission Date (format MM/DD/YYYY) -FOR HOSPITAL
                                                                         OUTPATIENTS/ASCs USE PATIENT VISIT DATE.
FL06            Statement Covers Period (Through)                        Discharge date (format MM/DD/YYYY) -FOR HOSPITAL OUTPATIENTS/ASCs USE PATIENT VISIT
                                                                         DATE WHEN PATIENT LEAVES FACILITY (can be same as FROM date).
FL07            Reserved (Upper Line)                                    Blank, Space padded
FL07            Reserved (Lower Line)                                    Blank, Space padded
FL08a           Patient Identifier                                       Patient identifier as assigned by payer (LEAVE THIS FIELD BLANK - SPACE FILLED)
                Patient Social Security Number                           Patient Social Security Number (LEAVE THIS FIELD BLANK - SPACE FILLED)
FL08b           Patient Name                                             Blank, Space padded
FL09a           Patient Street Address                                   Blank, Space padded
FL09b           Patient City                                             City
FL09c           Patient State                                            State code
FL09d           Patient Zip                                              Zip + 4 no hyphen (It is acceptable to only provide first 5 digits of zip code).
FL09e           Patient Country Code                                     Defines the country of the patient if not U.S.
FL10            Patient Birth Date                                       Date of birth (MM/DD/YYYY) must contain the slashes.
FL11            Patient Gender                                           Alphanumeric
                                                                         (M)ale, (F)emale, (U)nknown
                Patient Marital Status                                   Alphanumeric
                                                                         1=Single, 2=Married, 3=Life Partner, 4=Legally Separated, 5=Divorced, 6=Widow, 9=Unknown
                Patient Race                                             1=Native American/Alaskan, 2=Asian. Pacific Islander. 3=Black, 4=White, 5=Hispanic, 6=Other,
                                                                         9=Unknown
FL12            Admission(visit)/Start of Care Date                      For inpatient, the date of admission. for other, the start date for this episode of care
FL13            Admission Hour                                           The hour the patient was admitted for inpatient or outpatient care
FL14            Admission Type                                           Indicates the priority of inpatient admission
FL15            Referral Source                                          Indicates the source of the referral for the inpatient admission
FL16            Discharge Hour                                           Indicates the discharge hour of the patient from inpatient care
FL17            Discharge Status                                         Indicates the disposition or discharge staus of the inpatient on the discharge date
FL18-28         Condition Codes                                          A code(s) used to identify conditions or events relating to this bill that may affect processing
FL29            Accident State                                           State that the accident occurred
FL30            Reserved (Upper Line)                                    Blank, Space padded
FL30            Reserved (Lower Line)                                    Blank, Space padded
FL31-34         Occurrence Code
                Occurrence Date
FL35-36         Occurrence Span Code



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   NUBC                          Data Element                                                                 Definition
   Form
FL35-36
  Locator
            Occurrence Span Date From
            Occurrence Span Date Through
FL37        Reserved
FL38        Responsible Party Name/Address                     Blank, Space padded
FL39        Value Code                                         Values that identify data elements necessary to process this claim (See UB-04 data specifications
                                                               Manual)
FL39        Value Code Amount                                  Coded Value
FL40        Value Code                                         Values that identify data elements necessary to process this claim (See UB-04 data specifications
                                                               Manual)
FL40        Value Code Amount                                  Coded Value
FL41        Value Code                                         Values that identify data elements necessary to process this claim (See UB-04 data specifications
                                                               Manual). If all of the Value Code fields are filled, use FL81 Code-Code field with the appropriate
                                                               qualifier code(A$) to indicate that a Value code is being reported.
FL41        Value Code Amount                                  Coded Value
FL42        Revenue Code                                       Codes that identify specific accommodation, ancillary service or unique billing calculations or
                                                               arrangements.
FL43        Revenue Code Description                           The standard abbreviated description of the related revenue code categories.
FL44        Rate Codes                                         1. Healthcare Common Procedure Coding System (HCPCS) applicable to ancillary Service and
                                                               outpatient bills.
                                                               2. The accomodation rate for inpatient bills.
                                                               3. Health insurance Prospective Payment System (HIPPS) rate codes represent specific sets of
                                                               patient characteristics (or case- mix groups) on which payment determinations are made under
                                                               several prospective payment systems.
FL45        Service Date                                       The date the service was provided
FL46        Service Units                                      A quantitative measure of services rendered by revenue category to or for the patient.
FL47        Total Charges - Dollars                            Total charges, both covered and non-covered, for the primary payer pertaining to the related revenue
                                                               code
FL47        Total Charges - Cents                              Total charges, both covered and non-covered, for the primary payer pertaining to the related revenue
                                                               code
FL48        Non-covered Charges - Dollars                      Reflects the non-covered charges for the destination payer as it pertains to the related revenue code

FL48        Non-covered Charges - Cents                        Reflects the non-covered charges for the destination payer as it pertains to the related revenue code

FL49        Unlabled
FL42L23     Revenue Code
FL47L23     Total Summary Charges - Dollars                    Total charges, both covered and non-covered, for the primary payer pertaining to the related revenue
                                                               code
FL47L23     Total Summary Charges - Cents                      Total charges, both covered and non-covered, for the primary payer pertaining to the related revenue
                                                               code
FL48L23     Summary Non-covered Charges - Dollars              Total summary of Non-Covered charges for the destination payer.
FL48L23     Summary Non-covered Charges - Centes               Total summary of Non-Covered charges for the destination payer.
FL49L23     Unlabled
FL43L23     Current Page                                       An incrementing page count for each page. This corresponds to a patient record line.
FL44L23     Total Pages                                        Total number of pages/lines for the patient record
FL45L23     Creation Date                                      The date the bill was created or prepared for submission
FL50A       Payer Name - Primary                               Name of the health plan that the provider might expect some payment for the bill
FL50B       Payer Name - Secondary                             Name of the health plan that the provider might expect some payment for the bill
FL50C       Payer Name - Tertiary                              Name of the health plan that the provider might expect some payment for the bill
FL51A       Health Plan ID A                                   The number used by the health plan to identify itself. Previously known as provider number
FL51B       Health Plan ID B                                   The number used by the health plan to identify itself
FL51C       Health Plan ID C                                   The number used by the health plan to identify itself
FL52        Information Release - Primary                      Code indicates that the provider has a signed statement on file from the patient or legal representative
                                                               permitting the provider to release data to another organization. I = Informed consent. Y= Yes, provider
                                                               has signed statement on file.
FL52        Information Release - Secondary                    Code indicates that the provider has a signed statement on file from the patient or legal representative
                                                               permitting the provider to release data to another organization. I = Informed consent. Y= Yes, provider
                                                               has signed statement on file.
FL52        Information Release - Tertiary                     Code indicates that the provider has a signed statement on file from the patient or legal representative
                                                               permitting the provider to release data to another organization. I = Informed consent. Y= Yes, provider
                                                               has signed statement on file.
FL53        Benefits Assignment - Primary                      Code indicates provider has a signed form authoizing the third party payer to remit payment directly to
                                                               the provider. N = No, Y = Yes, W = Not Applicable
FL53        Benefits Assignment - Secondary                    Code indicates provider has a signed form authoizing the third party payer to remit payment directly to
                                                               the provider. N = No, Y = Yes, W = Not Applicable
FL53        Benefits Assignment - Tertiary                     Code indicates provider has a signed form authoizing the third party payer to remit payment directly to
                                                               the provider. N = No, Y = Yes, W = Not Applicable
FL54        Prior Payments Dollars - Primary                   The amount the provider has received to date by the health plan toward payment of this bill.
FL54        Prior Payments Cents - Primary
FL54        Prior Payments Dollars - Secondary                 The amount the provider has received to date by the health plan toward payment of this bill.
FL54        Prior Payments Cents - Secondary
FL54        Prior Payments Dollars- Tertiary                   The amount the provider has received to date by the health plan toward payment of this bill.
FL54        Prior Payments Cents- Tertiary
FL55        Estimated Amount Due Dollars - Primary             The amount estimated by the provider to be due from the indicated payer (estimated responsibility
                                                               less prior payments)



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   NUBC                          Data Element                                                                   Definition
   Form
  Locator
FL55        Estimated Amount Due Cents - Primary
FL55        Estimated Amount Due Dollars - Secondary            The amount estimated by the provider to be due from the indicated payer (estimated responsibility
                                                                less prior payments)
FL55        Estimated Amount Due Cents - Secondary
FL55        Estimated Amount Due Dollars - Tertiary             The amount estimated by the provider to be due from the indicated payer (estimated responsibility
                                                                less prior payments)
FL55        Estimated Amount Due Cents - Tertiary
FL56        NPI Other Provider ID                               The unique identification number assigned to the provider submitting the bill; NPI is the national
                                                                provider identifier. Note: NPI is ten characters in length.
FL57        Other Provider - Primary                            A unique id assigned to the provider submitting the bill by the health plan
FL57        Other Provider - Secondary                          A unique id assigned to the provider submitting the bill by the health plan
FL57        Other Provider - Tertiary                           A unique id assigned to the provider submitting the bill by the health plan
FL58        Insured Name - Primary                              Blank, Space padded
FL58        Insured Name - Secondary                            Blank, Space padded
FL58        Insured Name - Tertiary                             Blank, Space padded
FL59        Patient Relationship To Insured - Primary           Code indicating the relationship of the patient to the identified insured. 01=spouse, 18=Self, 19=Child,
                                                                20=Employee, 21=Unknown, 39=Organ Donor, 40=Cadaver, 53=Live Partner, G8=Other

FL59        Patient Relationship To Insured - Secondary         Code indicating the relationship of the patient to th eidentified insured. See Primary relationship to
                                                                insured for codes.
FL59        Patient Relationship To Insured - Tertiary          Code indicating the relationship of the patient to th eidentified insured. See Primary relationship to
                                                                insured for codes.
FL60        Insured Unique ID - Primary                         The unique number assigned by the health plan to the insured.
FL60        Insured Unique ID - Secondary
FL60        Insured Unique ID - Teriary
FL61        Insured Group Name - Primary                        The group or plan name through which the insurance is provided to the insured
FL61        Insured Group Name - Secondary                      The group or plan name through which the insurance is provided to the insured
FL61        Insured Group Name - Tertiary                       The group or plan name through which the insurance is provided to the insured
FL62        Insured Group Number - Primary                      The id, control number, or code assigned by the carrier or administrator to identify the group under
                                                                which the individual is covered.
FL62        Insured Group Number - Secondary                    The id, control number, or code assigned by the carrier or administrator to identify the group under
                                                                which the individual is covered.
FL62        Insured Group Number - Tertiary                     The id, control number, or code assigned by the carrier or administrator to identify the group under
                                                                which the individual is covered.
FL63        Treatment Authorization Code - Primary              A number or other indicator that designates that the treatment indicated on this bill has been
                                                                authorized by the payer.
FL63        Treatment Authorization Code - Secondary
FL63        Treatment Authorization Code - Teriary
FL64        Document Control Number - A                         The control number assigned to the original bill by the health plan or the health plan's fiscal agent as
                                                                part of their internal control
FL64        Document Control Number - B
FL64        Document Control Number - C
FL65        Employer Name - Primary                             Blank, Space padded
FL65        Employer Name - Secondary                           Blank, Space padded
FL65        Employer Name - Tertiary                            Blank, Space padded
FL66        ICD Version Indicator                               The qualifier that denotes the version of International Classification of Diseases (ICD) reported.
FL67        Principal Diagnosis Code                            ICD-9-CM codes describing the principal diagnosis (i.e., the condition established after study to be
                                                                chiefly responsible for occasioning the admission of the patient for care) See UB-07 Data
                                                                Specifications Manual for further detail
FL67        Other Diagnosis - A
FL67        Other Diagnosis - B
FL67        Other Diagnosis - C
FL67        Other Diagnosis - D
FL67        Other Diagnosis - E
FL67        Other Diagnosis - F
FL67        Other Diagnosis - G
FL67        Other Diagnosis - H
FL67        Other Diagnosis - I
FL67        Other Diagnosis - J
FL67        Other Diagnosis - K
FL67        Other Diagnosis - L
FL67        Other Diagnosis - M
FL67        Other Diagnosis - N
FL67        Other Diagnosis - O
FL67        Other Diagnosis - P
FL67        Other Diagnosis - Q
FL68        Unlabled - 68A
FL68        Unlabled - 68B
FL69        Admitting Diagnosis Code                            The ICD diagnosis code describing the patient's diagnosis at the time of admission.
FL70        Patient Visit Reason - A                            The ICD-CM diagnosis codes describing the patient's reason for visit at the time of oupatient
                                                                registration
FL70        Patient Visit Reason - B
FL70        Patient Visit Reason - C




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   NUBC                           Data Element                                                                        Definition
   Form
  Locator
FL71         PPS Code                                                 Prospective Payment System (PPS) Code assigned to the claim to identify the DRG based on the
                                                                      grouper software called for under contract with the primary payer. Note: Many workers compensation
                                                                      programs require this information.
FL72         External Cause of Injury Code - A                        The ICD diagnosis codes pertaining to external cause of injuries, poisoning, or adverse effect.
FL72         External Cause of Injury Code - B
FL72         External Cause of Injury Code - C
FL73         Unlabeled -73
FL74         Procedure Code - Principal                               The ICD code that identifies the inpatient principal procedure performed at the claim level during the
                                                                      period covered by this bill and the corresponding date.
FL74         Procedure Date - Principal
FL74         Procedure Code - Other A                                 The ICD codes identifying all significant procedures other than the principal procedure and the dates
                                                                      (identified by code) on which the procedures were performed. Report those that are most important for
                                                                      the episode of care and specifically any therapeutic procedures closely related to the principal
                                                                      diagnosis.
FL74         Procedure Date - Other A
FL74         Procedure Code - Other B
FL74         Procedure Date - Other B
FL74         Procedure Code - Other C
FL74         Procedure Date - Other C
FL74         Procedure Code - Other D
FL74         Procedure Date - Other D
FL74         Procedure Code - Other E
FL74         Procedure Date - Other E
FL75         Unlabeled - 75A
FL75         Unlabeled - 75B
FL75         Unlabeled - 75C
FL75         Unlabeled - 75D
FL76         Attending NPI                                            National Provider Identifier. Individual who has overall responsibility for the patient's medical care and
                                                                      treatment reported in this claim. Note: NPI is ten characters in length
FL76         Attending QUAL                                           0B=State license # (zero+B)
FL76         Attending ID                                             Secondary Identifier
FL76         Attending Last                                           Last Name
FL76         Attending First                                          First Name
FL77         Operating NPI                                            NPI of the individual with the primary responsibility of performing the surgical procedure(s)
FL77         Operating QUAL
FL77         Operating ID
FL77         Operating Last
FL77         Operating First
FL78         Other NPI - A                                            NPI of the individual corresponding to the provider type category.
FL78         Other QUAL - A                                           DN= Referring Provider, ZZ=Other Operating Physician or Assisting Surgeon, 82=Rendering Provider
                                                                      who delivers or competes a particular medical service or non-surgical procedure
FL78         Other ID - A
FL78         Other Last - A
FL78         Other First - A
FL79         Other NPI - B
FL79         Other QUAL - B
FL79         Other ID - B
FL79         Other Last - B
FL79         Other First - B
             Payer Code A - Primary                                   See Payer Codes Table Below
             Payer Code B - Secondary
             Payer Code C - Tertiary
FL80         Remarks - 1                                              Area to capture additional information necessary to adjudicate the claim
FL80         Remarks - 2
FL80         Remarks - 3
FL80         Remarks - 4
FL81         Code-Code-QUAL - A                                       Code Qualifier. To report additional codes related to a form locator (overflow) or to report externally
                                                                      maintained codes approved by the NUBC for inclusion in the institutional data set. See UB-04 Data
                                                                      specifications Manual
FL81         Code-Code-CODE - A
FL81         Code-Code-VALUE - A
FL81         Code-Code-QUAL - B
FL81         Code-Code-CODE - B
FL81         Code-Code-VALUE - B
FL81         Code-Code-QUAL - C
FL81         Code-Code-CODE - C
FL81         Code-Code-VALUE - C
FL81         Code-Code-QUAL - D
FL81         Code-Code-CODE - D
FL81         Code-Code-VALUE - D


PAYER CODES
         Payer codes are typically reported based on the best information known at time of final billing (several days after discharge)


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                                                               8c57b679-ede2-4fb1-a694-2282559cadf2.xls
                                          NEVADA HOSPITAL DISCHARGE REPORTING - FIELD DEFINITION




  NUBC                            Data Element                                                              Definition
  Form
 Locator

Payer Code                         Definition                                                              Comments
    10     Medicare
    11     Black Lung
    12     Charity                                          Cases in which the Hospital agreed to accept no or partial payment as the case met the Hospital's
                                                            Medical Financial Hardship Policy
    13     Hill Burton Free Care (HBFC)
    14     CHAMPUS / CHAMPVA
    15     No Longer in Use
    16     Nevada Medicaid
    17     Other Medicaid                                   People from out of the area (not NV)
    18     Self Pay                                         Cases in which the patient has no insurance coverage of any kind. This should include Pending
                                                            Medicaid or Pending County coverage
    19     Miscellaneous                                    Does not fit any other category
    20     Commercial Insurer                               Patients that have insurance coverage through a carrier that does not have a contract with the
                                                            Hospital allowing for payment at other than billed charges and should include cases in which the only
                                                            coverage is Motor Vehicle Insurance (BC/BS without a contract goes here)


    21     Negotiated Discounts                             Patients that have insurance coverage through a carrier that does have a contract with the Hospital
                                                            allowing for payment at other than billed charges and the product/benefit is a PPO (BC/BS PPO goes
                                                            here)
    22     Health Maintenance Organization                  Patients that have insurance coverage through a carrier that does have a contract with the Hospital
                                                            allowing for payment at other than billed charges and the product/benefit is an HMO (BC/BS HMO
                                                            goes here)
    23     County Indigent Referral                         Patient has already been approved for County Coverage
    24     All Worker's Compensation Cases
    25     No Longer in Use                                 In the past, 25-26 were used as Blue Cross/Blue Shield
    26     No Longer in Use                                 These will no longer be separated into their own categories.
    27     Medicare HMO
    28     Nevada Medicaid HMO                              Amerigroup & Sierra now do part of Nevada Medicaid HMO                                      BC/BS will
                                                            now be placed in 20,21,22. (see above)
    29     Section 1011 Undocumented Aliens
           Unknown                                          If Payer does not fit into any of the other categories, please contact the Center for Health Information
                                                            Analysis for assistance at 702-895-5436




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