UB04 claim form questions

Institutional billing specifications - set up the insurance claims.

To set up a specific form type for UB04, from the main directory select #8, #7, #3 and then enter the form type: (example: 564/964) and then select the 1st tab for the paper claim information. Right click on the 'Type of Claim" text box and select 2=h-UB04 (institutional specs)

For 'UB04/Institutional' type EDI, select the 2nd tab for EDI information. Right click on the 'Type of Claim" text box and select 2=h-UB04 (institutional specs)

Next you need to go into the patient's account, enter the insurance and the select the UB04 claiim question screens below.

OccCd/Dt 01 02 03 04 05 06 07 08 09 10

Occurrence Code

Please enter 1st occurrence code

Please enter 1st occurrence date

Please enter 2nd occurrence code

Please enter 2nd occurrence date

Please enter 3rd occurrence code

Please enter 3rd occurrence date

Please enter 4th occurrence code

Please enter 4th occurrence date

Please enter 5th occurrence code

Please enter 5th occurrence date

CondCode 11 12 13 14 15

Condition Code

Please enter 1st condition code

Please enter 2nd condition code

Please enter 3rd condition code

Please enter 4th condition code

Please enter 5th condition code

Bld Furn 16

Blood Furnished

Please enter the number of units of blood furnished.

Bld Rpl 17

Blood Replaced

Please enter the number of units of blood replaced.

Not Rpl 18

Not Replaced

Please enter the number of units of blood not replaced.

Bld Ded 19

Blood Deductible

Please enter number of non replaced deductible units of blood supplied.

VaCd/Amt 20 21 22 23 24 25 26 27

Value Code

Please enter 1st value code.

Please enter 1st value amount.

Please enter 2nd value code.

Please enter 2nd value amount.

Please enter 3rd value code.

Please enter 3rd value amount.

Please enter 4th value code.

Please enter 4th value amount.

Deductbl 28

Deductible Amount

Please enter the cash and/or blood deductible amounts.

CoInsurn 29

Co-insurance Amount

Please enter amount collected from the patient toward the co-insurance.

Employee ID 30

Please enter employee ID number.

EmInData 31

Employment Information Data

Please enter employment information (enter ABCPSFM).

EmStCode 32

Employment Status Code

Please enter employee status code 1= Full-time 2= Part-time

EmLocatn 33

Employer Location

Please enter the specific employer location, the city, plant, etc.

Remarks 34 35 36

Please enter 1st remark line.

Please enter 2nd remark line.

Please enter 3rd remark line.

Bill Type 37

Please enter bill type.