Injury Release Form for Auto Accidents

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Injury Release Form for Auto Accidents Powered By Docstoc
					                                                                 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                                Requred 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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                                                                                      f0f21ec7-fa47-4b14-a788-fce1a4c0b8f3.xls
                                                                 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=Uknown                                                                                           16     MARITAL STATUS
Patient Race                          448                          1        1=Native American/Alaskan, 2=Asian. Pacific   Required
                                                                            Islander. 3=Black, 4=White, 5=Hispanic,
                                                                            6=Other, 9=Unkown                                                                                         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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                                                                                      f0f21ec7-fa47-4b14-a788-fce1a4c0b8f3.xls
                                                              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
Occurance Code                     515      96       8          2        Alphanumeric                                      When there is an Occurrence Code       FL31-34
                                                                         Left Justified (See Code Book)                    that applies to this claim
Occurance Date                                                  10       Date
                                                                         MM/DD/YYYY
Occurnace 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
Occurance Span Date From                                        10       Date
                                                                         MM/DD/YYYY
Occurance 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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                                                                                   f0f21ec7-fa47-4b14-a788-fce1a4c0b8f3.xls
                                                                     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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                                                                                           f0f21ec7-fa47-4b14-a788-fce1a4c0b8f3.xls
                                                                        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
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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                                                                                             f0f21ec7-fa47-4b14-a788-fce1a4c0b8f3.xls
                                                                           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
Estimated Amount Due Cents - Tertiary          2989                          2        Numeric                                                                               FL55
                                                                                      Right Justified
National Provider Identifier(NPI)              2991                          15       Alphanumeric                                Required for all providers in the         FL56
                                                                                      Left Justified                              United States or its territories
Other Provider - Primary                       3006                          15       Alphanumeric                                Situational. Requierd 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. Requierd 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. Requierd 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
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


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                                                                                                f0f21ec7-fa47-4b14-a788-fce1a4c0b8f3.xls
                                                                        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 - 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

ICD Version Indicator                       3528                          1        Alphanumeric                                 Required                                 FL66




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                                                                                             f0f21ec7-fa47-4b14-a788-fce1a4c0b8f3.xls
                                                              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
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 Admissions:See the
                                                                         "Y" = Yes                                        Natioanl Uniform Billing Committee
                                                                         "N" = No                                         Official UB-04 data specifications
                                                                         "U" = No information in the Record               Manual for reporting requirements.
                                                                         "W" = Clinically Undetermined.
                                                                         "Z" = Exempt.
                                                                         Include "V" codes (Follow the official coding
                                                                         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                                      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
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




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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
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. See UB-04 data              FL70
                                                                            Left Justified                               specificatons Manual
Patient Visit Reason - B             3704                          7        Alphanumeric                                                                          FL70
                                                                            Left Justified
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
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



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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
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                                        Required                                 FL76
                                                                         Left Justified
                                                                         "0B" = State License Number                "1G" =
                                                                         Physician UPIN number,            "G2" =
                                                                         Provider Commercial
Attending ID                      3878                          9        Alphanumeric                                        Required                                 FL76
                                                                         Left Justified                                                                                        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                 FL77
                                                                         Left Justified                                    Available. See FL76.
Operating ID                      3928                          9        "0B" = State License Number
                                                                         Alphanumeric                               "1G" = Situational: Required When                 FL77
                                                                         Left Justified                                    Available. See FL76.                                   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
Other NPI - A                     3965                          11       Alphanumeric                                      Situational: Required When                 FL78
                                                                         Left Justified                                    Available. See FL76.
Other QUAL - A                    3976                          2        Alphanumeric                                      Situational: Required When                 FL78
                                                                         Left Justified                                    Available. See FL76.
Other ID - A                      3978                          9        Alphanumeric                                      Situational: Required When                 FL78
                                                                         Left Justified                                    Available. See FL76.
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
                                                                         Left Justified                                                                                50A     PAYER IDENTIFICATION
Payer Code B - Secondary          4067                          2        Alphanumeric                                Required
                                                                         Left Justified                                                                                50B     PAYER IDENTIFICATION
Payer Code C - Tertiary           4069                          2        Alphanumeric                                Required
                                                                         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

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

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




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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




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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                               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
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
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, (O)ther
            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     Occurance Code
            Occurance Date
FL35-36     Occurnace Span Code
            Occurance Span Date From
            Occurance 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.




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   NUBC                        Data Element                                                            Definition
   Form
  Locator
FL44        Rate Codes                                           1. Healthcare Common Procedure Coding System (HCPCS) applicable to ancillary
                                                                 Service and outpatient bills.
                                                                 2. The accomodation rate for inpatient bills.
                                                                 3. Health insurance Prospective Payment System (HIPPS) rate codes represent
                                                                 specific sets of patient characteristics (or case- mix groups) on which payment
                                                                 determinations are made under several prospective payment systems.

FL45        Service Date                                         The date the service was provided
FL46        Service Units                                        A quantitative measure of services rendered by revenue category to or for the
                                                                 patient.
FL47        Total Charges - Dollars                              Total charges, both covered and non-covered, for the primary payer pertaining to the
                                                                 related revenue code
FL47        Total Charges - Cents                                Total charges, both covered and non-covered, for the primary payer pertaining to the
                                                                 related revenue code
FL48        Non-covered Charges - Dollars                        Reflects the non-covered charges for the destination payer as it pertains to the
                                                                 related revenue code
FL48        Non-covered Charges - Cents                          Reflects the non-covered charges for the destination payer as it pertains to the
                                                                 related revenue code
FL49        Unlabled
FL42L23     Revenue Code
FL47L23     Total Summary Charges - Dollars                      Total charges, both covered and non-covered, for the primary payer pertaining to the
                                                                 related revenue code
FL47L23     Total Summary Charges - Cents                        Total charges, both covered and non-covered, for the primary payer pertaining to the
                                                                 related revenue code
FL48L23     Summary Non-covered Charges - Dollars                Total summary of Non-Covered charges for the destination payer.
FL48L23     Summary Non-covered Charges - Centes                 Total summary of Non-Covered charges for the destination payer.
FL49L23     Unlabled
FL43L23     Current Page                                         An incrementing page count for each page. This corresponds to a patient record
                                                                 line.
FL44L23     Total Pages                                          Total number of pages/lines for the patient record
FL45L23     Creation Date                                        The date the bill was created or prepared for submission
FL50A       Payer Name - Primary                                 Name of the health plan that the provider might expect some payment for the bill

FL50B       Payer Name - Secondary                               Name of the health plan that the provider might expect some payment for the bill

FL50C       Payer Name - Tertiary                                Name of the health plan that the provider might expect some payment for the bill

FL51A       Health Plan ID A                                     The number used by the health plan to identify itself. Previously known as provider
                                                                 number
FL51B       Health Plan ID B                                     The number used by the health plan to identify itself
FL51C       Health Plan ID C                                     The number used by the health plan to identify itself
FL52        Information Release - Primary                        Code indicates that the provider has a signed statement on file from the patient or
                                                                 legal representative permitting the provider to release data to another organization. I
                                                                 = Informed consent. Y= Yes, provider has signed statement on file.

FL52        Information Release - Secondary                      Code indicates that the provider has a signed statement on file from the patient or
                                                                 legal representative permitting the provider to release data to another organization. I
                                                                 = Informed consent. Y= Yes, provider has signed statement on file.

FL52        Information Release - Tertiary                       Code indicates that the provider has a signed statement on file from the patient or
                                                                 legal representative permitting the provider to release data to another organization. I
                                                                 = Informed consent. Y= Yes, provider has signed statement on file.

FL53        Benefits Assignment - Primary                        Code indicates provider has a signed form authoizing the third party payer to remit
                                                                 payment directly to the provider. N = No, Y = Yes, W = Not Applicable
FL53        Benefits Assignment - Secondary                      Code indicates provider has a signed form authoizing the third party payer to remit
                                                                 payment directly to the provider. N = No, Y = Yes, W = Not Applicable
FL53        Benefits Assignment - Tertiary                       Code indicates provider has a signed form authoizing the third party payer to remit
                                                                 payment directly to the provider. N = No, Y = Yes, W = Not Applicable
FL54        Prior Payments Dollars - Primary                     The amount the provider has received to date by the health plan toward payment of
                                                                 this bill.
FL54        Prior Payments Cents - Primary
FL54        Prior Payments Dollars - Secondary                   The amount the provider has received to date by the health plan toward payment of
                                                                 this bill.
FL54        Prior Payments Cents - Secondary
FL54        Prior Payments Dollars- Tertiary                     The amount the provider has received to date by the health plan toward payment of
                                                                 this bill.
FL54        Prior Payments Cents- Tertiary
FL55        Estimated Amount Due Dollars - Primary               The amount estimated by the provider to be due from the indicated payer (estimated
                                                                 responsibility less prior payments)
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



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   NUBC                        Data Element                                                             Definition
   Form
  Locator
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 th eidentified insured. 01=spouse,
                                                                  18=Self, 19=Child, 20=Employee, 21=Unknown, 39=Organ Donor, 40=Cadaver,
                                                                  53=Live Partner, G8=Other
FL59        Patient Relationship To Insured - Secondary           Code indicating the relationship of the patient to th eidentified insured. See Primary
                                                                  relationship to insured for codes.
FL59        Patient Relationship To Insured - Tertiary            Code indicating the relationship of the patient to th eidentified insured. See Primary
                                                                  relationship to insured for codes.
FL60        Insured Unique ID - Primary                           The unique number assigned by the health plan to the insured.
FL60        Insured Unique ID - Secondary
FL60        Insured Unique ID - Teriary
FL61        Insured Group Name - Primary                          The group or plan name through which the insurance is provided to the insured
FL61        Insured Group Name - Secondary                        The group or plan name through which the insurance is provided to the insured
FL61        Insured Group Name - Tertiary                         The group or plan name through which the insurance is provided to the insured
FL62        Insured Group Number - Primary                        The id, control number, or code assigned by the carrier or administrator to identify
                                                                  the group under which the individual is covered.
FL62        Insured Group Number - Secondary                      The id, control number, or code assigned by the carrier or administrator to identify
                                                                  the group under which the individual is covered.
FL62        Insured Group Number - Tertiary                       The id, control number, or code assigned by the carrier or administrator to identify
                                                                  the group under which the individual is covered.
FL63        Treatment Authorization Code - Primary                A number or other indicator that designates that the treatment indicated on this bill
                                                                  has been authorized by the payer.
FL63        Treatment Authorization Code - Secondary
FL63        Treatment Authorization Code - Teriary
FL64        Document Control Number - A                           The control number assigned to the original bill by the health plan or the health
                                                                  plan's fiscal agent as part of their internal control
FL64        Document Control Number - B
FL64        Document Control Number - C
FL65        Employer Name - Primary                               Blank, Space padded
FL65        Employer Name - Secondary                             Blank, Space padded
FL65        Employer Name - Tertiary                              Blank, Space padded
FL66        ICD Version Indicator                                 The qualifier that denotes the version of International Classification of Diseases
                                                                  (ICD) reported.
FL67        Principal Diagnosis Code                              ICD-9-CM codes describing the principal diagnosis (i.e., the condition established
                                                                  after study to be chiefly responsible for occasioning the admission of the patient for
                                                                  care) See UB-07 Data Specifications Manual for further detail
FL67        Other Diagnosis - A
FL67        Other Diagnosis - B
FL67        Other Diagnosis - C
FL67        Other Diagnosis - D
FL67        Other Diagnosis - E
FL67        Other Diagnosis - F
FL67        Other Diagnosis - G
FL67        Other Diagnosis - H
FL67        Other Diagnosis - I
FL67        Other Diagnosis - J
FL67        Other Diagnosis - K
FL67        Other Diagnosis - L
FL67        Other Diagnosis - M
FL67        Other Diagnosis - N
FL67        Other Diagnosis - O
FL67        Other Diagnosis - P
FL67        Other Diagnosis - Q
FL68        Unlabled - 68A
FL68        Unlabled - 68B
FL69        Admitting Diagnosis Code                              The ICD diagnosis code describing the patient's diagnosis at the time of admission.

FL70        Patient Visit Reason - A                              The ICD-CM diagnosis codes describing the patient's reason for visit at the time of
                                                                  oupatient registration
FL70        Patient Visit Reason - B
FL70        Patient Visit Reason - C
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.



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                               NEVADA HOSPITAL DISCHARGE REPORTING - FIELD DEFINITION




   NUBC                        Data Element                                                        Definition
   Form
  Locator
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 #
FL76        Attending ID                                    Secondary Identifier
FL76        Attending Last                                  Last Name
FL76        Attending First                                 First Name
FL77        Operating NPI                                   NPI of the individual with the primary responsibility of performing the surgical
                                                            procedure(s)
FL77        Operating QUAL
FL77        Operating ID
FL77        Operating Last
FL77        Operating First
FL78        Other NPI - A                                   NPI of the individual corresponding to the provider type category.
FL78        Other QUAL - A                                  DN= Referring Provider, ZZ=Other Operating Physician or Assisting Surgeon,
                                                            82=Rendering Provider who delivers or competes a particular medical service or
                                                            non-surgical procedure
FL78        Other ID - A
FL78        Other Last - A
FL78        Other First - A
FL79        Other NPI - B
FL79        Other QUAL - B
FL79        Other ID - B
FL79        Other Last - B
FL79        Other First - B
            Payer Code A - Primary                          See Payer Codes Table Below
            Payer Code B - Secondary
            Payer Code C - Tertiary
FL80        Remarks - 1                                     Area to capture additional information necessary to adjudicate the claim
FL80        Remarks - 2
FL80        Remarks - 3
FL80        Remarks - 4
FL81        Code-Code-QUAL - A                              Code Qualifier. To report additional codes related to a form locator (overflow) or to
                                                            report externally maintained codes approved by the NUBC for inclusion in the
                                                            institutional data set. See UB-04 Data specifications Manual
FL81        Code-Code-CODE - A
FL81        Code-Code-VALUE - A
FL81        Code-Code-QUAL - B
FL81        Code-Code-CODE - B
FL81        Code-Code-VALUE - B
FL81        Code-Code-QUAL - C
FL81        Code-Code-CODE - C
FL81        Code-Code-VALUE - C
FL81        Code-Code-QUAL - D
FL81        Code-Code-CODE - D
FL81        Code-Code-VALUE - D




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                                NEVADA HOSPITAL DISCHARGE REPORTING - FIELD DEFINITION




   NUBC                      Data Element                                                               Definition
   Form
  Locator
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
     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
     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
     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
     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                                          BC/BS will now be placed in 20,21,22. (see above)
     28      Nevada Medicaid HMO
     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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DOCUMENT INFO
Description: Injury Release Form for Auto Accidents document sample