Get documents about "Injury Release Form for Auto Accidents
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Injury Release Form for Auto Accidents document sample
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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
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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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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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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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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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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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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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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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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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
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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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
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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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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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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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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