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					The UB04 manual is required for the definition of fields. A few definitions have been included in this file, but most ha
been left out. The UB04 manual is copyrighted, and this prevents us from including extensive information.
The manual can be purchased at: http://www.nvha.net/webstore.htm
There are other locations at which the manual can be purchased. The Center does not endorse
any particular one.
 d in this file, but most have
ve information.
                                                                 NEVADA HOSPITAL DISCHARGE REPORTING - FIELD LAYOUT




                     Data Element   Starting Group    Group    Number of                     Field Attributes                   Required Field?             NUBC      1354     1354 Nevada Field
                                    Position Length   Repeat   Characters                                                                                   Form     Nevada
                                                                                                                                                           Locator   UB-92
Provider Name                          1                           25       Alphanumeric                             Required                               FL01
                                                                            Left Justified
Provider Address                      26                           25       Alphanumeric                             Required                               FL01
                                                                            Left Justified
Provider City                         51                           12       Alphanumeric                             Required                               FL01
                                                                            Left Justified
Provider State                        63                           2        Alphanumeric                             Required                               FL01
                                                                            Left Justified
Provider Zip Code                     65                           10       Alphanumeric                             Required                               FL01
                                                                            Left Justified 89523-5058
Provider Telephone Number             75                           12       Alphanumeric                             Required                               FL01
                                                                            Left Justified 999-999-9999
Provider Fax Number                   87                           12       Alphanumeric                             When Available                         FL01
                                                                            Left Justified 999-999-9999
Provider Country Code                 99                           2        Alphanumeric                             Required when address is outside of    FL01
                                                                            Left Justified                           the United States
Pay-to Name                           101                          25       Alphanumeric                             Required when address for payment      FL02
                                                                            Left Justified                           is different than FL01
Pay-to Address                        126                          25       Alphanumeric                             Required when address for payment      FL02
                                                                            Left Justified                           is different than FL01
Pay-to City                           151                          16       Alphanumeric                             Required when address for payment      FL02
                                                                            Left Justified                           is different than FL01
Pay-to State                          167                          2        Alphanumeric                             Required when address for payment      FL02
                                                                            Left Justified                           is different than FL01
Pay-to Zip                            169                          5        Alphanumeric                             Required when address for payment      FL02
                                                                            Left Justified 89523                     is different than FL01
Reserved FL02                         174                          25       Space filled                                                                    FL02

Patient Control Number                199                          20       Alphanumeric                             Required                              FL03a
                                                                            Left Justified                                                                             3      PATIENT ID NUMBER
Medical/Health Record Number          219                          24       Space filled                                                                   FL03b
                                                                                                                                                                       23     MEDICAL RECORD NUMBER
Type of Bill (First three digits)     243                          3        Alphanumeric                             Required                               FL04
                                                                            Left Justified                                                                             4      BILL TYPE
Type of Bill Frequency Code           246                          1        Alphanumeric                             Required
(Last alphanumeric)                                                         Left Justified
Federal Tax Number (Upper line)       247                          4        Alphanumeric                             Optional                               FL05
                                                                            Left Justified
Federal Tax Number (Lower line)       251                          10       Alphanumeric                             Required                               FL05
                                                                            Left Justified 99-9999999
Statement Covers Period (From)        261                          10       Date                                     Required                               FL06
                                                                            MM/DD/YYYY
Statement Covers Period (Through)     271                          10       Date                                     Required                               FL06
                                                                            MM/DD/YYYY                                                                                 6      DATE OF DISCHARGE
Reserved FL07A                        281                          7        Space filled                                                                   FL07A

Reserved FL07B                        288                          8        Space filled                                                                   FL07B

Patient Identifier                    296                          19       Space filled                                                                   FL08a




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                                                                 NEVADA HOSPITAL DISCHARGE REPORTING - FIELD LAYOUT




                     Data Element   Starting Group    Group    Number of                   Field Attributes                           Required Field?               NUBC      1354     1354 Nevada Field
                                    Position Length   Repeat   Characters                                                                                           Form     Nevada
                                                                                                                                                                   Locator   UB-92
Patient Social Security Number        315                          9        Space filled
                                                                                                                                                                               60     SOCIAL SECURITY NUMBER
Patient Name                          324                          29       Space filled                                                                           FL08b

Patient Street Address                353                          40       Space filled                                                                           FL09a

Patient City                          393                          30       Alphanumeric                                  Required                                 FL09b
                                                                            Left Justified
Patient State                         423                          2        Alphanumeric                                  Required                                 FL09c
                                                                            Left Justified
Patient Zip                           425                          9        Numeric                                       Required                                 FL09d
                                                                            Left Justified 999999999
                                                                            Spaced filled = Unknown                                                                            13     ZIPCODE
Patient Country Code                  434                          2        Alphanumeric                                  If outside the U.S.                      FL09e
                                                                            Left Justified. Part I of ISO 3166
Patient Birth Date                    436                          10       Date                                          Required.                                 FL10
                                                                            MM/DD/YYYY
                                                                            00/00/0000 = Unknown                                                                               14     BIRTHDATE
Patient Gender                        446                          1        Alphanumeric                                  Required                                  FL11
                                                                            (M)ale, (F)emale, (U)nknown                                                                        15     GENDER
Patient Marital Status                447                          1        Alphanumeric                                  Required                                  FL81
                                                                            1=Single, 2=Married, 3=Life Partner,
                                                                            4=Legally Separated, 5=Divorced, 6=Widow,
                                                                            9=Unknown                                                                                          16     MARITAL STATUS
Patient Race                          448                          1        1=Native American/Alaskan, 2=Asian. Pacific   Required                                  FL81
                                                                            Islander. 3=Black, 4=White, 5=Hispanic,
                                                                            6=Other, 9=Unknown                                                                                        RACE
Admission/Start of Care Date          449                          10       Date                                          Required for inpatients and bill types    FL12
                                                                            MM/DD/YYYY                                    032x, 033x, and 034x                                 17     DATE OF ADMISSION
Admission Hour                        459                          2        Alphanumeric                                  Required for inpatients except 021x       FL13
                                                                            00 through 23                                                                                      18     ADMISSION HOUR
Admission Type                        461                          1        Alphanumeric                                  Required                                  FL14
                                                                            1 through 9                                                                                        19     TYPE OF ADMISSION
Referral Source                       462                          1        Alphanumeric                                  Required                                  FL15
                                                                            Left Justified (See Code Book)                                                                     20     SOURCE OF ADMISSION
Discharge Hour                        463                          2        Alphanumeric                                  Required on inpatients with               FL16
                                                                            00 through 23                                 frequency code of 1 or 4, except for
                                                                                                                          bill type 021x                                       21     DISCHARGE HOUR
Discharge Status                      465                          2        Alphanumeric                                  Required                                  FL17
                                                                            00 through 99 (See Code Book)                                                                      22     DISCHARGE STATUS
Condition Codes                       467      22       11         2        Alphanumeric                                  Required when there is a condition       FL18-28
                                                                            Left Justified (See Code Book)                code relating to this claim
Accident State                        489                          2        Alphanumeric                                  Only for auto accidents                   FL29
                                                                            Left Justified
Reserved FL30A                        491                          11       Space filled                                                                           FL30A

Reserved FL30B                        502                          13       Space filled                                                                           FL30B




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                  Data Element   Starting Group    Group    Number of                    Field Attributes                             Required Field?              NUBC      1354     1354 Nevada Field
                                 Position Length   Repeat   Characters                                                                                             Form     Nevada
                                                                                                                                                                  Locator   UB-92
Occurrence Code                    515      96       8          2        Alphanumeric                                      When there is an Occurrence Code       FL31-34
                                                                         Left Justified (See Code Book)                    that applies to this claim
Occurrence Date                                                 10       Date
                                                                         MM/DD/YYYY
Occurrence Span Code               611      88       4          2        Alphanumeric                                      When there is an Occurrence Span       FL35-36
                                                                         Left Justified (See Code Book)                    Code that applies to this claim
Occurrence Span Date From                                       10       Date
                                                                         MM/DD/YYYY
Occurrence Span Date Through                                    10       Date
                                                                         MM/DD/YYYY
Reserved FL37                      699                          8        Space filled                                                                              FL37

Responsible Party Name/Address     707     200       5          40       Space filled                                                                              FL38

Value Code                         907      44       4          2        Alphanumeric                                      Required when there is a value code     FL39
                                                                         Left Justified. All positions fully Coded         that applies to this claim. (See UB-
Value Code Amount                                               9        Numeric                                           04 Specifications Manual)
                                                                         Right Justified, Negative numbers are not
                                                                         allowed except in FL41.
Value Code                         951      44       4          2        Alphanumeric                                      Required when there is a value code     FL40
                                                                         Left Justified. All positions fully Coded         that applies to this claim. (See UB-
Value Code Amount                                               9        Numeric                                           04 Specifications Manual)
                                                                         Right Justified, Negative numbers are not
                                                                         allowed except in FL41.
Value Code                         995      44       4          2        Alphanumeric                                      Required when there is a value code     FL41
                                                                         Left Justified. All positions fully Coded         that applies to this claim. (See UB-
Value Code Amount                                               9        Numeric                                           04 Specifications Manual)
                                                                         Right Justified, '-' prefix allowed.
Revenue Code                      1039     1738      22         4        Alphanumeric                                      Required                                FL42
                                                                         Left Justified. All positions fully Coded. Last
                                                                         position must be a numeric 0-9 denoting
                                                                         subcategory.Listed in Ascending numeric
                                                                         order, by date of Service. (See Code Book)                                                           42     REVENUE CODE
Revenue Code Description                                        24       Alphanumeric                                      Optional                                FL43
                                                                         Left Justified
Rate Codes                                                      14       Alphanumeric                                      Situational. See UB-04 data             FL44
                                                                         Format Depends on bill type. (See Code            specificatons Manual
Service Date                                                    10       Book)
                                                                         Date                                              Required when there is an               FL45
                                                                         MM/DD/YYYY                                        associated Revenue code that
Service Units                                                   7        Numeric                                           applies to this claim                   FL46
                                                                         Right Justified                                                                                      46     UNITS OF SERVICE
Total Charges - Dollars                                         7        Numeric                                                                                   FL47
                                                                         Right Justified.                                                                                     47     CHARGES
Total Charges - Cents                                           2        Numeric                                                                                   FL47
                                                                         Right Justified.                                                                                     47     CHARGES
Non-covered Charges - Dollars                                   7        Numeric                                           Situational. See UB-04 data             FL48
                                                                         Right Justified.                                  specificatons Manual
Non-covered Charges - Cents                                     2        Numeric                                           Situational. See UB-04 data             FL48
                                                                         Right Justified.                                  specificatons Manual
Reserved FL49                                                   2        Space filled                                                                              FL49



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                                                                     NEVADA HOSPITAL DISCHARGE REPORTING - FIELD LAYOUT




                 Data Element           Starting Group    Group    Number of                       Field Attributes                         Required Field?             NUBC      1354     1354 Nevada Field
                                        Position Length   Repeat   Characters                                                                                           Form     Nevada
                                                                                                                                                                       Locator   UB-92
Revenue Code                             2777                          4        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.
Summary Total Charges - Dollars          2781                          7        Numeric                                        Required on Patients last line of the   FL47L23
                                                                                Right Justified.                               format file. See FL43L23. Space fill
                                                                                                                               on lines preceding total line.                      47     TOTAL CHARGE
Summary Total Charges - Cents            2788                          2                                                                                               FL47L23
                                                                                                                                                                                   47     TOTAL CHARGE
Summary Non-covered Charges - Dollars    2790                          7                                                       When FL48 has been populated,           FL48L23
                                                                                                                               required on Patients last line of the
Summary Non-covered Charges - Cents      2797                          2                                                       format file. See FL43L23. Space fill    FL48L23
                                                                                                                               on lines preceding total line.
Reserved 49L23                           2799                          2        Space filled                                                                           FL49L23

Current Page                             2801                          3        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.
Total Pages                              2804                          3        Numeric                                          Required                              FL44L23
                                                                                Left Justified.
                                                                                Total number of lines for this Patient record in
                                                                                the format file. See Current Page FL43L23

Creation Date                            2807                          10       Date                                           Required                                FL45L23
                                                                                MM/DD/YYYY
Payer Name - Primary                     2817                          23       Alphanumeric                                   Required                                FL50A
                                                                                Left Justified
Payer Name - Secondary                   2840                          23       Alphanumeric                                   Situational. Required when other        FL50B
                                                                                Left Justified                                 payers are known to potentially be
                                                                                                                               involved in paying this claim
Payer Name - Tertiary                    2863                          23       Alphanumeric                                   Situational. Required when other        FL50C
                                                                                Left Justified                                 payers are known to potentially be
                                                                                                                               involved in paying this claim




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                   Data Element            Starting Group    Group    Number of                      Field Attributes                   Required Field?            NUBC      1354    1354 Nevada Field
                                           Position Length   Repeat   Characters                                                                                   Form     Nevada
                                                                                                                                                                  Locator   UB-92
Health Plan ID A                            2886                          15       Alphanumeric                              Required                              FL51A
                                                                                   Left Justified
Health Plan ID B                            2901                          15       Alphanumeric                              Situational. Required when other     FL51B
                                                                                   Left Justified                            payers are known to potentially be
                                                                                                                             involved in paying this claim
Health Plan ID C                            2916                          15       Alphanumeric                              Situational. Required when other     FL51C
                                                                                   Left Justified                            payers are known to potentially be
                                                                                                                             involved in paying this claim
Information Release - Primary               2931                          1        Alphanumeric                              Required                              FL52

Information Release - Secondary             2932                          1        Alphanumeric                              Situational                           FL52

Information Release - Tertiary              2933                          1        Alphanumeric                              Situational                           FL52

Benefits Assignment - Primary               2934                          1        Alphanumeric                              Required                              FL53

Benefits Assignment - Secondary             2935                          1        Alphanumeric                              Situational                           FL53

Benefits Assignment - Tertiary              2936                          1        Alphanumeric                              Situational                           FL53

Prior Payments Dollars - Primary            2937                          7        Numeric                                   Situational. Required when the        FL54
                                                                                   Right Justified                           indicated payer has paid an amount
                                                                                                                             to the provider towards this bill

Prior Payments Cents - Primary              2944                          2        Numeric                                                                         FL54
                                                                                   Right Justified
Prior Payments Dollars - Secondary          2946                          7        Numeric                                   Situational. Required when the        FL54
                                                                                   Right Justified                           indicated payer has paid an amount
                                                                                                                             to the provider towards this bill

Prior Payments Cents - Secondary            2953                          2        Numeric                                                                         FL54
                                                                                   Right Justified
Prior Payments Dollars - Tertiary           2955                          7        Numeric                                   Situational. Required when the        FL54
                                                                                   Right Justified                           indicated payer has paid an amount
                                                                                                                             to the provider towards this bill

Prior Payments Cents - Tertiary             2962                          2        Numeric                                                                         FL54
                                                                                   Right Justified
Estimated Amount Due Dollars - Primary      2964                          7        Numeric                                   Situational. Required when the        FL55
                                                                                   Right Justified                           provider estimates an amount due
                                                                                                                             from the indicated payer
Estimated Amount Due Cents - Primary        2971                          2        Numeric                                                                         FL55
                                                                                   Right Justified
Estimated Amount Due Dollars - Secondary    2973                          7        Numeric                                   Situational. Required when the        FL55
                                                                                   Right Justified                           provider estimates an amount due
                                                                                                                             from the indicated payer
Estimated Amount Due Cents - Secondary      2980                          2        Numeric                                                                         FL55
                                                                                   Right Justified
Estimated Amount Due Dollars - Tertiary     2982                          7        Numeric                                   Situational. Required when the        FL55
                                                                                   Right Justified                           provider estimates an amount due
                                                                                                                             from the indicated payer




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                  Data Element                Starting Group    Group    Number of                      Field Attributes                   Required Field?                NUBC      1354    1354 Nevada Field
                                              Position Length   Repeat   Characters                                                                                       Form     Nevada
                                                                                                                                                                         Locator   UB-92
Estimated Amount Due Cents - Tertiary          2989                          2        Numeric                                                                             FL55
                                                                                      Right Justified
National Provider Identifier(NPI)              2991                          15       Alphanumeric                              Situational: Required for all             FL56
                                                                                      Left Justified                            providers in the United States or its
                                                                                                                                territories when the provider is
                                                                                                                                eligible for an NPI.
Other Provider - Primary                       3006                          15       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

Other Provider - Secondary                     3021                          15       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

Other Provider - Tertiary                      3036                          15       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

Insured Name - Primary                         3051                          25       Space filled                                                                        FL58

Insured Name - Secondary                       3076                          25       Space filled                                                                        FL58




Insured Name - Tertiary                        3101                          25       Space filled                                                                        FL58




Patient Relationship To Insured - Primary      3126                          2        Alphanumeric                              Required                                  FL59
                                                                                      Left Justified
Patient Relationship To Insured - Secondary    3128                          2        Alphanumeric                              Situational. Required when other          FL59
                                                                                      Left Justified                            payers are known to potentially be
                                                                                                                                involved in paying this claim
Patient Relationship To Insured - Tertiary     3130                          2        Alphanumeric                              Situational. Required when other          FL59
                                                                                      Left Justified                            payers are known to potentially be
                                                                                                                                involved in paying this claim
Insured Unique ID - Primary                    3132                          20       Space filled                                                                        FL60

Insured Unique ID - Secondary                  3152                          20       Space filled                                                                        FL60

Insured Unique ID - Tertiary                   3172                          20       Space filled                                                                        FL60
Insured Group Name - Primary                   3192                          14       Alphanumeric                              Situational. Required if available and    FL61
                                                                                      Left Justified                            FL62 is not used




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                                                                        NEVADA HOSPITAL DISCHARGE REPORTING - FIELD LAYOUT




                 Data Element              Starting Group    Group    Number of                     Field Attributes                      Required Field?                NUBC      1354    1354 Nevada Field
                                           Position Length   Repeat   Characters                                                                                         Form     Nevada
                                                                                                                                                                        Locator   UB-92
Insured Group Name - Secondary              3206                          14       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
Insured Group Name - Tertiary               3220                          14       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
Insured Group Number - Primary              3234                          17       Alphanumeric                                 Situational. Required when the           FL62
                                                                                   Left Justified                               insured's identification card shows a
                                                                                                                                group number
Insured Group Number - Secondary            3251                          17       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
Insured Group Number - Tertiary             3268                          17       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
Treatment Authorization Code - Primary      3285                          30       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
Treatment Authorization Code - Secondary    3315                          30       Alphanumeric                                 See FL63 primary                         FL63
                                                                                   Left Justified
Treatment Authorization Code - Tertiary     3345                          30       Alphanumeric                                 See FL63 primary                         FL63
                                                                                   Left Justified
Document Control Number - A                 3375                          26       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

Document Control Number - B                 3401                          26       Alphanumeric                                 See FL64 A                               FL64
                                                                                   Left Justified
Document Control Number - C                 3427                          26       Alphanumeric                                                                          FL64
                                                                                   Left Justified
Employer Name - Primary                     3453                          25       Blank out by filling with space characters                                            FL65
Employer Name - Secondary                   3478                          25       Space filled                                                                          FL65

Employer Name - Tertiary                    3503                          25       Space filled                                                                          FL65




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                  Data Element   Starting Group    Group    Number of                   Field Attributes                             Required Field?             NUBC      1354     1354 Nevada Field
                                 Position Length   Repeat   Characters                                                                                           Form     Nevada
                                                                                                                                                                Locator   UB-92
ICD Version Indicator             3528                          1        Alphanumeric                                     Required                               FL66

Principal Diagnosis Code          3529                          8        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.                                       required on Principal Diagnosis
                                                                         "N" = No.                                        Code as well as all reported Other
                                                                         "U" = No information in the Record.              Diagnoses Codes (A-Q).
                                                                         "W" = Clinically Undetermined.
                                                                         "1" = Exempt. POA indicator is also              See the National Uniform Billing
                                                                         considered exempt.                               Committee Official UB-04 data
                                                                                                                          specifications Manual for reporting
                                                                         Include "V" codes (Follow the official coding    requirements.
                                                                         guidelines for ICD reporting)                                                                      67     ICD-9-CM OR ICD-10-CM Principal Diagnosis Code
Other Diagnosis - A               3537                          8        Alphanumeric                                     Situational. Required when other      FL67A
                                                                         See FL67 Principal Diagnosis for usage           conditions coexist or develop
                                                                                                                          subsequently during the patient's
                                                                                                                          treatment.
                                                                                                                          Present on Admission (POA) is not
                                                                                                                          required when reporting other
                                                                                                                          outpatient Diagnoses (A-Q).                     68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - B               3545                          8        Alphanumeric                                     See FL67 A                            FL67B
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - C               3553                          8        Alphanumeric                                     See FL67 A                            FL67C
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - D               3561                          8        Alphanumeric                                     See FL67 A                            FL67D
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - E               3569                          8        Alphanumeric                                     See FL67 A                            FL67E
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - F               3577                          8        Alphanumeric                                     See FL67 A                            FL67F
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - G               3585                          8        Alphanumeric                                     See FL67 A                            FL67G
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - H               3593                          8        Alphanumeric                                     See FL67 A                            FL67H
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - I               3601                          8        Alphanumeric                                     See FL67 A                             FL67I
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - J               3609                          8        Alphanumeric                                     See FL67 A                            FL67J
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - K               3617                          8        Alphanumeric                                     See FL67 A                            FL67K
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - L               3625                          8        Alphanumeric                                     See FL67 A                            FL67L
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - M               3633                          8        Alphanumeric                                     See FL67 A                            FL67M
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - N               3641                          8        Alphanumeric                                     See FL67 A                            FL67N
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - O               3649                          8        Alphanumeric                                     See FL67 A                            FL67O
                                                                         See FL67 Principal Diagnosis for usage                                                           68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code




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                  Data Element      Starting Group    Group    Number of                     Field Attributes                      Required Field?                NUBC      1354     1354 Nevada Field
                                    Position Length   Repeat   Characters                                                                                         Form     Nevada
                                                                                                                                                                 Locator   UB-92
Other Diagnosis - P                  3657                          8        Alphanumeric                                 See FL67 A                               FL67P
                                                                            See FL67 Principal Diagnosis for usage                                                         68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Other Diagnosis - Q                  3665                          8        Alphanumeric                                 See FL67 A                              FL67Q
                                                                            See FL67 Principal Diagnosis for usage                                                         68-75    SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code
Reserved - 68A                       3673                          8        Space filled                                                                         FL68A

Reserved - 68B                       3681                          9        Space filled                                                                         FL68B

Admitting Diagnosis Code             3690                          7        Alphanumeric                                 Situational. Required when claim         FL69
                                                                            Left Justified                               involves an inpatient admission.                    76     ICD-9-CM or ICD-10-CM Admiting Diagnosis Code
Patient Visit Reason - A             3697                          7        Alphanumeric                                 Situational.                             FL70
                                                                            Left Justified                               1. Required when available for all
                                                                                                                         unscheduled outpatient visits. An
                                                                                                                         “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
Patient Visit Reason - B             3704                          7        Alphanumeric                                 Revenue Codes 045X, 0516,                FL70
                                                                            Left Justified                               0526, or 0762 (Observation Room).
Patient Visit Reason - C             3711                          7        Alphanumeric                                                                          FL70
                                                                            Left Justified
PPS Code                             3718                          4        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
External Cause of Injury Code - A    3722                          8        Alphanumeric                                 Situational. Required when an injury,    FL72
                                                                            Left Justified                               poisoning, or adverse effect is the
                                                                                                                         cause for seeking medical treatment
                                                                                                                         or occurs during the medical
                                                                                                                         treatment.
External Cause of Injury Code - B    3730                          8        Alphanumeric                                                                          FL72
                                                                            Left Justified
External Cause of Injury Code - C    3738                          8        Alphanumeric                                                                          FL72
                                                                            Left Justified
Reserved FL73                        3746                          1        Space filled                                                                          FL73

Procedure Code - Principal           3747                          7        Alphanumeric                                 Situational. Required on inpatient       FL74
                                                                            Left Justified. No decimals.                 claims when a procedure was
                                                                                                                         performed. Not required for
                                                                                                                         outpatient claims.                                 80A     ICD-9-CM OR ICD-10-CM Principal PROCEDURE CODE
Procedure Date - Principal           3754                          10       Date                                                                                  FL74
                                                                            MM/DD/YYYY                                                                                      80B     DATE OF PRINCIPAL PROCEDURE CODE
Procedure Code - Other A             3764                          7        Alphanumeric                                 Situational. Required on inpatient       FL74
                                                                            Left Justified. No decimals.                 claims when additional procedures
                                                                                                                         must be reported. Not required for
                                                                                                                         outpatient claims.                                81A-E    SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE COD
Procedure Date - Other A             3771                          10       Date                                                                                  FL74
                                                                            MM/DD/YYYY
Procedure Code - Other B             3781                          7        Alphanumeric                                 See FL74 Other A                         FL74
                                                                            Left Justified. No decimals.                                                                   81A-E    SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE COD




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                  Data Element   Starting Group    Group    Number of                     Field Attributes                           Required Field?                NUBC       1354        1354 Nevada Field
                                 Position Length   Repeat   Characters                                                                                              Form      Nevada
                                                                                                                                                                   Locator    UB-92
Procedure Date - Other B          3788                          10       Date                                                                                       FL74
                                                                         MM/DD/YYYY
Procedure Code - Other C          3798                          7        Alphanumeric                                      See FL74 Other A                         FL74
                                                                         Left Justified. No decimals.                                                                          81A-E      SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE COD
Procedure Date - Other C          3805                          10       Date                                                                                       FL74
                                                                         MM/DD/YYYY
Procedure Code - Other D          3815                          7        Alphanumeric                                      See FL74 Other A                         FL74
                                                                         Left Justified. No decimals.                                                                          81A-E      SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE COD
Procedure Date - Other D          3822                          10       MM/DD/YYYY                                                                                 FL74

Procedure Code - Other E          3832                          7        Alphanumeric                                      See FL74 Other A                         FL74
                                                                         Left Justified. No decimals.                                                                          81A-E      SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE COD
Procedure Date - Other E          3839                          10       Date                                                                                       FL74
                                                                         MM/DD/YYYY
Reserved FL75A                    3849                          4        Space filled                                                                              FL75A

Reserved FL75B                    3853                          4        Space filled                                                                              FL75B

Reserved FL75C                    3857                          4        Space filled                                                                              FL75C

Reserved FL75D                    3861                          4        Space filled                                                                              FL75D

Attending NPI                     3865                          11       Alphanumeric                                      Required when the provider has an        FL76
                                                                         Left Justified                                    NPI
Attending QUAL                    3876                          2        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
Attending ID                      3878                          9        Alphanumeric                                      Situational: Required if there is no     FL76
                                                                         Left Justified                                    NPI.                                              82B or 82E
Attending Last                    3887                          16       Alphanumeric                                      Situational. Required when the claim     FL76
                                                                         Left Justified                                    contains any services other than non-
                                                                                                                           scheduled transportation claims
                                                                                                                                                                                82C       ATTENDING PHYSICIAN LAST NAME
Attending First                   3903                          12       Alphanumeric                                      See FL76 Attending Last                  FL76
                                                                         Left Justified                                                                                         82D       ATTENDING PHYSICIAN FIRST NAME
Operating NPI                     3915                          11       Alphanumeric                                      Situational: Required When               FL77
                                                                         Left Justified                                    Available. See FL76.
Operating QUAL                    3926                          2        Alphanumeric                                      Situational: Required when available     FL77
                                                                         Left Justified                                    and if there is no NPI. Order of
                                                                         "0B" = State License Number                "1G" = preference for these codes is 1)
                                                                         Physician UPIN number,              "G2" =        UPIN, 2) State License Number, 3)
                                                                         Provider Commercial                               Provider Commercial

Operating ID                      3928                          9        Alphanumeric                                      Situational: Required when available     FL77
                                                                         Left Justified                                    and if there is no NPI.                              83B
Operating Last                    3937                          16       Alphanumeric                                      Situational: Required When               FL77
                                                                         Left Justified                                    Available. See FL76.                                 83C       OPERATING PHYSICIAN LAST NAME
Operating First                   3953                          12       Alphanumeric                                      Situational: Required When               FL77
                                                                         Left Justified                                    Available. See FL76.                                 83D       OPERATING PHYSICIAN FIRST NAME



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                  Data Element   Starting Group    Group    Number of                     Field Attributes                  Required Field?               NUBC      1354    1354 Nevada Field
                                 Position Length   Repeat   Characters                                                                                    Form     Nevada
                                                                                                                                                         Locator   UB-92
Other NPI - A                     3965                          11       Alphanumeric                             Situational: Required When              FL78
                                                                         Left Justified                           Available. See FL76.
Other QUAL - A                    3976                          2        Alphanumeric                             Situational: Required when available    FL78
                                                                         Left Justified                           and if there is no NPI. Order of
                                                                                                                  preference for these codes is 1)
                                                                                                                  UPIN, 2) State License Number, 3)
                                                                                                                  Provider Commercial
Other ID - A                      3978                          9        Alphanumeric                             Situational: Required when available    FL78
                                                                         Left Justified                           and if there is no Other NPI.


Other Last - A                    3987                          16       Alphanumeric                             Situational: Required When              FL78
                                                                         Left Justified                           Available. See FL76.
Other First - A                   4003                          12       Alphanumeric                             Situational: Required When              FL78
                                                                         Left Justified                           Available. See FL76.




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                  Data Element   Starting Group    Group    Number of                      Field Attributes                  Required Field?                NUBC      1354     1354 Nevada Field
                                 Position Length   Repeat   Characters                                                                                      Form     Nevada
                                                                                                                                                           Locator   UB-92
Other NPI - B                     4015                          11       Alphanumeric                              Situational: Required When               FL79
                                                                         Left Justified                            Available. See FL76.
Other QUAL - B                    4026                          2        Alphanumeric                              Situational: Required When               FL79
                                                                         Left Justified                            Available. See FL76.
Other ID - B                      4028                          9        Alphanumeric                              Situational: Required When               FL79
                                                                         Left Justified                            Available. See FL76.
Other Last - B                    4037                          16       Alphanumeric                              Situational: Required When               FL79
                                                                         Left Justified                            Available. See FL76.
Other First - B                   4053                          12       Alphanumeric                              Situational: Required When               FL79
                                                                         Left Justified                            Available. See FL76.
Payer Code A - Primary            4065                          2        Alphanumeric                              Required (definitions for valid codes
                                                                         Left Justified                            can be found at the bottom of the
                                                                                                                   field definitions page.)
                                                                                                                                                                      50A     PAYER IDENTIFICATION
Payer Code B - Secondary          4067                          2        Alphanumeric                              Required when available
                                                                         Left Justified                                                                               50B     PAYER IDENTIFICATION
Payer Code C - Tertiary           4069                          2        Alphanumeric                              Required when available
                                                                         Left Justified                                                                               50C     PAYER IDENTIFICATION
Remarks - 1                       4071                          19       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.
Remarks - 2                       4090                          24       Alphanumeric                                                                       FL80
                                                                         Left Justified
Remarks - 3                       4114                          24       Alphanumeric                                                                       FL80
                                                                         Left Justified
Remarks - 4                       4138                          24       Alphanumeric                                                                       FL80
                                                                         Left Justified
Code-Code-QUAL - A                4162                          2        Alphanumeric                              Situational.                            FL81A
                                                                         Left Justified
Code-Code-CODE - A                4164                          10       Alphanumeric                              Situational.                            FL81A
                                                                         Left Justified
Code-Code-VALUE - A               4174                          12       Numeric                                   Situational.                            FL81A
                                                                         Right Justified
Code-Code-QUAL - B                4186                          2        Alphanumeric                              Situational.                            FL81B
                                                                         Left Justified
Code-Code-CODE - B                4188                          10       Alphanumeric                              Situational.                            FL81B
                                                                         Left Justified
Code-Code-VALUE - B               4198                          12       Numeric                                   Situational.                            FL81B
                                                                         Right Justified
Code-Code-QUAL - C                4210                          2        Alphanumeric                              Situational.                            FL81C
                                                                         Left Justified
Code-Code-CODE - C                4212                          10       Alphanumeric                              Situational.                            FL81C
                                                                         Left Justified
Code-Code-VALUE - C               4222                          12       Numeric                                   Situational.                            FL81C
                                                                         Right Justified
Code-Code-QUAL - D                4234                          2        Alphanumeric                              Situational.                            FL81D
                                                                         Left Justified
Code-Code-CODE - D                4236                          10       Alphanumeric                              Situational.                            FL81D
                                                                         Left Justified


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                    Data Element   Starting Group    Group    Number of                      Field Attributes                  Required Field?    NUBC      1354    1354 Nevada Field
                                   Position Length   Repeat   Characters                                                                          Form     Nevada
                                                                                                                                                 Locator   UB-92
Code-Code-VALUE - D                 4246                          12       Numeric                                   Situational.                 FL81D
                                                                           Right Justified




Total line length                   4257




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ICD-9-CM OR ICD-10-CM Principal Diagnosis Code




SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code




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SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code




ICD-9-CM or ICD-10-CM Admiting Diagnosis Code




ICD-9-CM OR ICD-10-CM Principal PROCEDURE CODE




SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE CODES




SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE CODES




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SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE CODES




SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE CODES




SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE CODES




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                           28 Of 71

           6e25594b-368b-4c10-bc88-2b8035b2dc4f.xls
                   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

Admission (Visit) Type                 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                                   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
                 Field Attributes              Required Field?             NUBC      1354
                                                                           Form     Nevada
                                                                          Locator   UB-92
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                        Required                               FL01
Left Justified 999-999-9999
Alphanumeric                        When Available                         FL01
Left Justified 999-999-9999
Alphanumeric                        Required when address is outside of    FL01
Left Justified                      the United States
Alphanumeric                        Required when address for payment      FL02
Left Justified                      is different than FL01
Alphanumeric                        Required when address for payment      FL02
Left Justified                      is different than FL01
Alphanumeric                        Required when address for payment      FL02
Left Justified                      is different than FL01
Alphanumeric                        Required when address for payment      FL02
Left Justified                      is different than FL01
Alphanumeric                        Required when address for payment      FL02
Left Justified 89523                is different than FL01
Space filled                                                               FL02

Alphanumeric                        Required                              FL03a
Left Justified                                                                        3
Space filled                                                              FL03b
                                                                                      23
Alphanumeric                        Required (see page 13-15 of UB04       FL04
Left Justified                      manual)                                           4
Alphanumeric                        Required (see page 16-19 of UB04
Left Justified                      manual)
Alphanumeric                        Optional                               FL05
Left Justified
Alphanumeric                        Required                               FL05
Left Justified 99-9999999
Date                                Required                               FL06
MM/DD/YYYY
Date                                Required (see page 21 of UB04          FL06
MM/DD/YYYY                          manual) - For all services received
                                    on a single day, use the same date
                                    for “From” and
                                    “Through”.
                                                                                      6
Space filled                                                              FL07A
Space filled                                                                           FL07B

Space filled                                                                           FL08a

Space filled
                                                                                               60
Space filled                                                                           FL08b

Space filled                                                                           FL09a

Alphanumeric                                  Required                                 FL09b
Left Justified
Alphanumeric                                  Required                                 FL09c
Left Justified
Numeric                                       Required                                 FL09d
Left Justified 999999999
Spaced filled = Unknown                                                                        13
Alphanumeric                                  If outside the U.S.                      FL09e
Left Justified. Part I of ISO 3166
Date                                          Required.                                FL10
MM/DD/YYYY
00/00/0000 = Unknown                                                                           14
Alphanumeric                                  Required                                 FL11
(M)ale, (F)emale, (U)nknown                                                                    15
Alphanumeric                                  Required                                 FL81
1=Single, 2=Married, 3=Life Partner,
4=Legally Separated, 5=Divorced, 6=Widow,
9=Unknown                                                                                      16
1=Native American/Alaskan, 2=Asian. Pacific   Required
Islander. 3=Black, 4=White, 5=Hispanic,
6=Other, 9=Unknown
Date                                          Required                                 FL12
MM/DD/YYYY                                                                                     17
Alphanumeric                                  Required                                 FL13
00 through 23                                                                                  18
Alphanumeric                                  Required (page 30 of UB04 manual)        FL14
1 through 9                                                                                    19
Alphanumeric                                  Situational: When available              FL15
Left Justified (See Code Book)                                                                 20
Alphanumeric                                  Situational: Bills may continue for up   FL16
00 through 23                                 to 120 days before one is closed out
                                              and a new one opened. The
                                              Discharge Hour would normally only
                                              show up on the final modification of
                                              the bill.
                                                                                               21
Alphanumeric                                  Situational: Bills may continue for up   FL17
00 through 99 (See Code Book)                 to 120 days before one is closed out
                                              and a new one opened. The
                                              Discharge Status would normally
                                              only show up on the final
                                              modification of the bill.


                                                                                               22
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                                                                              FL30A

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
Date
MM/DD/YYYY
Date
MM/DD/YYYY
Space filled                                                                               FL37

Space filled                                                                               FL38

Alphanumeric                                      Required when there is a value code      FL39
Left Justified. All positions fully Coded         that applies to this claim. (See UB-
Numeric                                           04 Specifications Manual)
Right Justified, Negative numbers are not
allowed except in FL41.
Alphanumeric                                      Required when there is a value code      FL40
Left Justified. All positions fully Coded         that applies to this claim. (See UB-
Numeric                                           04 Specifications Manual)
Right Justified, Negative numbers are not
allowed except in FL41.
Alphanumeric                                      Required when there is a value code      FL41
Left Justified. All positions fully Coded         that applies to this claim. (See UB-
Numeric                                           04 Specifications Manual)
Right Justified, '-' prefix allowed.
Alphanumeric                                      Required                                 FL42
Left Justified. All positions fully Coded. Last
position must be a numeric 0-9 denoting
subcategory.Listed in Ascending numeric
order, by date of Service. (See Code Book)                                                          42
Alphanumeric                                      Optional                                 FL43
Left Justified
Alphanumeric                                      The Healthcare Common Procedure          FL44
Format Depends on bill type. (See Code            Coding System (HCPCS) applicable
Book)                                             to ancillary service and outpatient
left-justified for HCPCS and HIPPS Rate           bills.HCPCS and HIPPS Rate
Codes.                                            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                                FL45
Date Format: MM/DD/YYYY


Numeric                                     Required                                 FL46
Right Justified                             When HCPCS 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.
                                                                                              46
Numeric                                                                              FL47
Right Justified.                                                                              47
Numeric                                                                              FL47
Right Justified.
                                                                                              47
Numeric                                                                              FL48
Right Justified.
Numeric                                     National Uniform Billing Committee       FL48
Right Justified.                            Official UB-04 Data Specifications
Space filled                                Manual 2009
                                            AHA                                      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.                    47
                                                                                    FL47L23
                                                                                              47
                                            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                                                                        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                                           Required                              FL45L23
MM/DD/YYYY                                     Line 23 refers to the Creation Date
                                               of the bill (the date bill was
                                               created/printed)).



Alphanumeric                                   Required                              FL50A
Left Justified
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                                   Required                              FL51A
Left Justified
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                                              FL58

Space filled                                              FL58




Space filled                                              FL58




Alphanumeric     Required                                 FL59
Left Justified
Alphanumeric     Situational. Required when other         FL59
Left Justified   payers are known to potentially be
                 involved in paying this claim
Alphanumeric     Situational. Required when other         FL59
Left Justified   payers are known to potentially be
                 involved in paying this claim
Space filled                                              FL60

Space filled                                              FL60

Space filled                                              FL60
Alphanumeric     Situational. Required if available and   FL61
Left Justified   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                                                                             FL64
Left Justified
Blank out by filling with space characters                                               FL65
Space filled                                                                             FL65

Space filled                                                                             FL65

Alphanumeric                                     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 only
"Y" = Yes.                                       required for inpatient records (not
"N" = No.                                        outpatient)
"U" = No information in the Record.
"W" = Clinically Undetermined.                   See the National Uniform Billing
"1" = Exempt. A {blank} or empty POA             Committee Official UB-04 data
indicator is also considered exempt.             specifications Manual for reporting
                                                 requirements.
Include "V" codes (Follow the official coding
guidelines for ICD reporting)                                                                   67
Alphanumeric                             Situational. Required when other        FL67A
See FL67 Principal Diagnosis for usage   conditions coexist or develop
                                         subsequently during the patient's
                                         treatment.
                                                                                         68-75
Alphanumeric                             See FL67 A                              FL67B
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67C
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67D
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67E
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67F
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67G
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67H
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67I
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67J
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67K
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67L
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67M
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67N
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67O
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67P
See FL67 Principal Diagnosis for usage                                                   68-75
Alphanumeric                             See FL67 A                              FL67Q
See FL67 Principal Diagnosis for usage                                                   68-75
Space filled                                                                     FL68A

Space filled                                                                     FL68B

Alphanumeric                             Situational. Required when claim        FL69
Left Justified                           involves an inpatient admission.                 76
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
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                                                                         FL72
Left Justified
Alphanumeric                                                                         FL72
Left Justified
Space filled                                                                         FL73

Alphanumeric                                 Situational. Required on inpatient      FL74
Left Justified. No decimals.                 claims when a procedure was
                                             performed. Not required for
                                             outpatient claims.                              80A
Date                                                                                 FL74
MM/DD/YYYY                                                                                   80B
Alphanumeric                                 Situational. Required on inpatient      FL74
Left Justified. No decimals.                 claims when additional procedures
                                             must be reported. Not required for
                                             outpatient claims.                              81A-E
Date                                                                                 FL74
MM/DD/YYYY
Alphanumeric                                 See FL74 Other A                        FL74
Left Justified. No decimals.                                                                 81A-E
Date                                                                                 FL74
MM/DD/YYYY
Alphanumeric                                 See FL74 Other A                        FL74
Left Justified. No decimals.                                                                 81A-E
Date                                                                                 FL74
MM/DD/YYYY
Alphanumeric                                 See FL74 Other A                        FL74
Left Justified. No decimals.                                                                 81A-E
MM/DD/YYYY                                                                           FL74

Alphanumeric                                 See FL74 Other A                        FL74
Left Justified. No decimals.                                                                 81A-E
Date                                                                                 FL74
MM/DD/YYYY
Space filled                                                                         FL75A

Space filled                                                                         FL75B
Space filled                                                                       FL75C

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.
                                                                                           82B or 82E
Alphanumeric                                Situational. Required when the claim   FL76
Left Justified                              contains any services other than
                                            non-scheduled transportation claims
                                                                                              82C
Alphanumeric                                See FL76 Attending Last                FL76
Left Justified                                                                                82D
Alphanumeric                                Situational: Required When             FL77
Left Justified                              Available. See FL76.
Alphanumeric                                Situational: Required when available   FL77
Left Justified                              and if there is no NPI. Order of
"0B" = State License Number          "1G" = preference for these codes is 1)
Physician UPIN number,        "G2" =        UPIN, 2) State License Number, 3)
Provider Commercial                         Provider Commercial

Alphanumeric                                Situational: Required when available   FL77
Left Justified                              and if there is no NPI.
                                                                                              83B
Alphanumeric                                Situational: Required When             FL77
Left Justified                              Available. See FL76.                              83C
Alphanumeric                                Situational: Required When             FL77
Left Justified                              Available. See FL76.                              83D
Alphanumeric                                Situational: Required When             FL78
Left Justified                              Available. See FL76.
Alphanumeric                                Situational: Required when available   FL78
Left Justified                              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 available   FL78
Left Justified                              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 codes
Left Justified    can be found at the bottom of the
                  field definitions page.)
                                                                  50A
Alphanumeric      Required when available
Left Justified                                                    50B
Alphanumeric      Required when available
Left Justified                                                    50C
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                                              FL80
Left Justified
Alphanumeric                                              FL80
Left Justified
Alphanumeric                                              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
 1354 Nevada Field




PATIENT ID NUMBER

MEDICAL RECORD NUMBER

BILL TYPE




DATE OF DISCHARGE
SOCIAL SECURITY NUMBER




ZIPCODE




BIRTHDATE

GENDER



MARITAL STATUS


RACE

DATE OF ADMISSION

ADMISSION HOUR

TYPE OF ADMISSION

SOURCE OF ADMISSION




DISCHARGE HOUR




DISCHARGE STATUS
REVENUE CODE
UNITS OF SERVICE

CHARGES


CHARGES




TOTAL CHARGE

TOTAL CHARGE
ICD-9-CM OR ICD-10-CM Principal Diagnosis Code
SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code

SECONDARY ICD-9-CM OR ICD-10-CM Diagnosis Code




ICD-9-CM or ICD-10-CM Admiting Diagnosis Code
ICD-9-CM OR ICD-10-CM Principal PROCEDURE CODE

DATE OF PRINCIPAL PROCEDURE CODE



SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE CODES




SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE CODES




SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE CODES




SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE CODES




SECONDARY ICD-9-CM OR ICD-10-CM PROCEDURE CODES
ATTENDING PHYSICIAN LAST NAME

ATTENDING PHYSICIAN FIRST NAME




OPERATING PHYSICIAN LAST NAME

OPERATING PHYSICIAN FIRST NAME
PAYER IDENTIFICATION

PAYER IDENTIFICATION

PAYER IDENTIFICATION
                                 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                                        Name of Payer
FL02        Pay-to Address                                     Address of Payer
FL02        Pay-to City                                        City of Payer
FL02        Pay-to State                                       State of Payer
FL02        Pay-to Zip                                         Pay-to Zip
FL02        Unused
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
FL04        Type of Bill (First three digits)                  Specifies In/outpatient
            Type of Bill Frequency Code (Last alphanumeric)    Forth digit of Type of Bill Field
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
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
FL06        Statement Covers Period (Through)                  Discharge date
FL07        Reserved (Upper Line)
FL07        Reserved (Lower Line)
FL08a       Patient Identifier                                 Patient identifier as assigned by payer
            Patient Social Security Number                     Patient Social Security Number
FL08b       Patient Name                                       Blank, Space padded
FL09a       Patient Street Address                             Address
FL09b       Patient City                                       City


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   NUBC                         Data Element                                                           Definition
   Form
  Locator
FL09c       Patient State                                    State code
FL09d       Patient Zip                                      Zip + 4 no hyphen
FL09e       Patient Country Code                             Defines the country of the patient if not U.S.
FL10        Patient Birth Date                               Date of birth
FL11        Patient Gender
            Patient Marital Status                           (S)ingle, (M)arried, (U)nknown
            Patient Race                                     1=Native American/Alaskan, 2=Asian. Pacific Islander. 3=Black, 4=White, 5=Hispanic,
                                                             6=Other, 9=Unkown
FL12        Admission/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 the admission/visit
FL15        Referral Source                                  Indicates the source of the referal for the admission/visit
FL16        Discharge Hour                                   Indicates the discharge hour of the patient from inpatient care
FL17        Discharge Status                                 Indicates the disposition or discharge staus of the patien 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)
FL30        Reserved (Lower Line)
FL31-34     Occurrence Code
            Occurrence Date
FL35-36     Occurrence Span Code
            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



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   NUBC                        Data Element                                                                 Definition
   Form
  Locator
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)
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.



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   NUBC                        Data Element                                                       Definition
   Form
  Locator
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
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



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   NUBC                         Data Element                                                               Definition
   Form
  Locator
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)

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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