1.

(blank)

Enter the provider's name, (physical address -- service location) city, state, zip code, and telephone number.

2.

(blank)

The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for provider's return address for returned mail.)

3a.

PAT CNTL #

The provider may use this optional field for accounting purposes. It appears on the RA beside the letters “MRN.” Up to 16 alphanumeric characters are accepted.

3b.

MED REC #

Required. Enter up to 15 alphanumeric characters.

4.

TYPE OF BILL

See the UB-04 manual. Four-digit code with a leading zero that indicates the type of bill.

5.

FED TAX NO

The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN).

6.

STATEMENT COVERS PERIOD

Enter the same date in both sections of the field. Format: MMDDYY.

7.

Not used

Reserved for assignment by the NUBC.

8a.

PATIENT NAME

Enter the patient's last name and first name. Middle initial is optional.

8b.

(blank)

Not required.

9.

PATIENT ADDRESS

Enter the patient's full mailing address. Optional.

10.

BIRTH DATE

Enter the patient's date of birth. Format: MMDDYYYY.

11.

SEX

Enter M for male, F for female, or U for unknown.

12.

ADMISSION DATE

Not required.

13.

ADMISSION HR

Not required.

14.

ADMISSION TYPE

Not required.

15.

ADMISSION SRC

Not required.

16.

DHR

Not applicable.

17.

STAT

Not applicable.

18.-28.

CONDITION CODES

Required when applicable. See the UB-04 Manual for requirements and for the codes used to identify conditions or events relating to this bill.

29.

ACDT STATE

Not required.

30.

(blank)

Unassigned data field.

31.-34.

OCCURRENCE CODES AND DATES

Required when applicable. See the UB-04 Manual.

35.-36.

OCCURRENCE SPAN CODES AND DATES

See the UB-04 Manual.

37.

Not used

Reserved for assignment by the NUBC.

38.

Responsible Party Name and Address

See the UB-04 Manual.

AMOUNT

Not applicable.

40.

VALUE CODES

Not applicable.

41.

VALUE CODES

Not applicable.

42.

REV CD

Enter a revenue code when applicable. See the UB-04 Manual and this provider manual.

43.

DESCRIPTION

See the UB-04 Manual. Required for paper claims only.

44.

HCPCS/RATE/HIPPS CODE

Enter a surgery or diagnostic procedure code.

Date format: MMDDYY.

46.

SERV UNITS

Enter the applicable number of units.

47.

TOTAL CHARGES

Enter the product of the charge per unit times the number of units.

48.

NON-COVERED CHARGES

Not applicable.

49.

Not used

Reserved for assignment by the NUBC.

50.

PAYER NAME

Line A is required. See the UB-04 for additional regulations.

51.

HEALTH PLAN ID

Report the HIPPA National Plan Identifier; otherwise report the legacy/proprietary number.

52.

REL INFO

Required. See the UB-04 Manual.

53.

ASG BEN

Required. See “Notes” at field 53 in the UB-04 Manual.

54.

PRIOR PAYMENTS

Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. * Do not include in this total the automatically deducted Medicaid or ARKids First-B co-payments.

55.

EST AMOUNT DUE

Situational. See the UB-04 Manual.

56.

NPI

Not required.

57.

OTHER PRV ID

Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider.

58. A, B, C

INSURED'S NAME

Comply with the UB-04 Manual's instructions.

59. A, B, C

P REL

Not applicable. Comply with the UB-04 Manual's instructions when there are other payers.

60. A, B, C

INSURED'S UNIQUE ID

Enter the patient's Medicaid identification number on the first line of the field.

61. A, B, C

GROUP NAME

Not applicable. See UB-04 Manual when there are other payers.

62. A, B, C

INSURANCE GROUP NO

When applicable, follow instructions for fields 60 and 61.

63. A, B, C

TREATMENT AUTHORIZATION CODES

Enter any applicable prior authorization or benefit extension number in field 63A.

64. A, B, C

DOCUMENT CONTROL NUMBER

Field used internally by Arkansas Medicaid. No provider input.

65. A, B, C

EMPLOYER NAME

When applicable, based upon fields 51 through 62, enter the name(s) of the individuals and entities that provide health care coverage for the patient (or may be liable).

Comply with the UB-04 Manual's instructions on claims processing requirements.

67. A-H

(blank)

Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received. Fields are available for up to 8 codes.

68.

Not used

Reserved for assignment by the NUBC.

69.

ADMIT DX

Not applicable.

70.

PATIENT REASON DX

Not applicable.

71.

PPS CODE

Not required.

72

ECI

See the UB-04 Manual. Required when applicable (for example, TPL and torts).

73.

Not used

Reserved for assignment by the NUBC.

74.

PRINCIPAL PROCEDURE CODE AND DATE and OTHER PROCEDURE CODES AND DATES

Not applicable.

75.

Not used

Reserved for assignment by the NUBC.

FIRST

Enter the surgeon's first name.

FIRST

Not applicable.

FIRST

Enter the referring physician's first name.

79.

OTHER NPI/QUAL/LAST/FIRS

Not used.

80.

REMARKS

For provider's use.

81.

Not used

Reserved for assignment by the NUBC.