016.06.41-242.410. Completion of CMS-1450 (UB-04) Claim Form
AR ADC 016.06.41-242.410Arkansas Administrative Code
Ark. Admin. Code 016.06.41-242.410
016.06.41-242.410. Completion of CMS-1450 (UB-04) Claim Form
Field # | Field name | Description |
|---|---|---|
1. | (blank) | Inpatient and Outpatient: 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 # | Inpatient and Outpatient: 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 # | Inpatient and Outpatient: Required. Enter up to 15 alphanumeric characters. |
4. | TYPE OF BILL | Inpatient and Outpatient: 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 covered beginning and ending service dates. Format: MMDDYY. |
Inpatient: Enter the dates of the first and last covered days in the FROM and THROUGH fields. | ||
The FROM and THROUGH dates cannot span the State's fiscal year end (June 30) or the provider's fiscal year end. | ||
To file correctly for covered inpatient days that span a fiscal year end: | ||
1. Submit one interim claim (a first claim or a continuing claim, as applicable) on which the THROUGH date is the last day of the fiscal year that ended during the stay. | ||
On a first claim or a continuing claim, the patient status code in field 17 must indicate that the beneficiary is still a patient on the indicated THROUGH date. | ||
2. Submit a second interim claim (a continuing claim or a last claim, as applicable) on which the FROM date is the first day of the new fiscal year. | ||
When the discharge date is the first day of the provider's fiscal year or the state's fiscal year, only one (bill type: admission through discharge) claim is necessary, because Medicaid does not reimburse a hospital for a discharge day unless the discharge day is also the first covered day of the inpatient stay. | ||
When an inpatient is discharged on the same date he or she is admitted, the day is covered when the TYPE OF BILL code indicates that the claim is for admission through discharge, the STAT (patient status) code indicates discharge or transfer, and the FROM and THROUGH dates are identical. | ||
Outpatient: To bill on a single claim for outpatient services occurring on multiple dates, enter the beginning and ending service dates in the FROM and THROUGH fields of this field. | ||
The dates in this field must fall within the same fiscal year -- the state's fiscal year and the hospital's fiscal year. | ||
When billing for multiple dates of service on a single claim, a date of service is required in field 45 for each HCPCS code in field 44 and/or each revenue code in field 42. | ||
7. | (blank) | Reserved for assignment by the NUBC. |
8a. | PATIENT NAME | Inpatient and Outpatient: Enter the patient's last name and first name. Middle initial Is optional. |
8b. | (blank) | Not required. |
9. | PATIENT ADDRESS | Inpatient and Outpatient: Enter the patient's full mailing address. Optional. |
10. | BIRTH DATE | Inpatient and Outpatient: Enter the patient's date of birth. Format: MMDDYYYY. |
11. | SEX | Inpatient and Outpatient: Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Inpatient: Enter the inpatient admission date. Format: MMDDYY. |
Outpatient: Not required. | ||
13. | ADMISSION HR | Inpatient and Outpatient: Enter the national code that corresponds to the hour during which the patient was admitted for inpatient care. |
14. | ADMISSION TYPE | Inpatient: Enter the code from the UB-04 Manual that indicates the priority of this inpatient admission. |
Outpatient: Not required. | ||
15. | ADMISSION SRC | Inpatient and Outpatient: Admission source. |
16. | DHR | Inpatient: See the UB-04 Manual. Required. Enter the hour the patient was discharged from inpatient care. |
17. | STAT | Inpatient: Enter the national code indicating the patient's status on the Statement Covers Period THROUGH date (field 6). |
Outpatient: Not applicable. | ||
18.-28. | CONDITION CODES | Inpatient and Outpatient: 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 | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | Inpatient: Enter the dates of the first and last days approved, per the facility's PSRO/UR plan, in the FROM and THROUGH fields. See the UB-04 Manual. Format: MMDDYY. |
Outpatient: 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. |
39. | VALUE CODES | Outpatient: Not required. |
a. | CODE | Inpatient: |
b. | AMOUNT | Enter 80. |
CODE | Enter number of covered days. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted line. | |
AMOUNT | Enter 81. | |
Enter number of non-covered days. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted line. | ||
40. | VALUE CODES | Not required. |
41. | VALUE CODES | Not required. |
42. | REV CD | Inpatient and Outpatient: See the UB-04 Manual. |
43. | DESCRIPTION | See the UB-04 Manual. |
44. | HCPCS/RATE/HIPPS CODE | See the UB-04 Manual. |
45. | SERV DATE | Inpatient: Not applicable. |
Outpatient: See the UB-04 Manual. Format: MMDDYY. | ||
46. | SERV UNITS | Comply with the UB-04 Manual's instructions when applicable to Medicaid. |
47. | TOTAL CHARGES | Comply with the UB-04 Manual's instructions when applicable to Medicaid. |
48. | NON-COVERED CHARGES | See the UB-04 Manual, line item “Total” under “Reporting.” |
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 HIPAA National Plan Identifier; otherwise report the legacy/proprietary number. |
52. | REL INFO | Required when applicable. See the UB-04 Manual. |
53. | ASG BEN | Required. See “Notes” at field 53 in the UB-04 Manual. |
54. | PRIOR PAYMENTS | Inpatient and Outpatient: Required when applicable. 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. See the UB-04 Manual. |
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 on first line of field. |
58. A, B, C | INSURED'S NAME | Inpatient and Outpatient: Comply with the UB-04 Manual's instructions when applicable to Medicaid. |
59. A, B, C | P REL | Inpatient and Outpatient: Comply with the UB-04 Manual's instructions when applicable to Medicaid. |
60. A, B, C | INSURED'S UNIQUE ID | Inpatient and Outpatient: Enter the patient's Medicaid identification number on first line of field. |
61. A, B, C | GROUP NAME | Inpatient and Outpatient: Using the plan name if the patient is insured by another payer or other payers, follow instructions for field 60. |
62. A, B, C | INSURANCE GROUP NO | Inpatient and Outpatient: When applicable, follow instructions for fields 60 and 61. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Inpatient: Enter any applicable prior authorization, benefit extension, or MUMP certification control number in field 63A. |
Outpatient: 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 | Inpatient and Outpatient: 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). |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. |
Qualifier Code “9” designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. | ||
Qualifier Code “0” designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. | ||
Comply with the UB-04 Manual's instructions on claims processing requirements. | ||
67. A-H | (blank) | Inpatient and Outpatient: 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 or the length of stay. Fields are available for up to 8 codes. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Required for inpatient. See the UB-04 Manual. |
70. | PATIENT REASON DX | See the UB-04 Manual. |
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 | Inpatient: Required on inpatient claims when a procedure was performed. On all interim claims, enter the codes for all procedures during the hospital stay. |
CODE | Outpatient: Not applicable. | |
DATE | Principal procedure code. | |
Format: MMDDYY. | ||
74a-74e | OTHER PROCEDURE | Inpatient: Required on inpatient claims when a procedure was performed. On all interim claims, enter the codes for all procedures during the hospital stay. |
CODE | Outpatient: Not applicable. | |
DATE | Other procedure code(s). | |
Format: MMDDYY. | ||
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary attending physician. | |
FIRST | Enter the first name of the primary attending physician. | |
77. | OPERATING NPI NPI | not required. |
QUAL | Not applicable. | |
LAST | Not applicable. | |
FIRST | Not applicable. | |
78. | OTHER NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary care physician. | |
FIRST | Enter the first name of the primary care physician. | |
79. | OTHER NPI/QUAL/LAST/FIRS | Not used. |
80. | REMARKS | For provider's use. |
81. | Not used | Reserved for assignment by the NUBC. |
Credits
Eff. July 1, 2007. Amended March 7, 2014.
<Editor’s Note: Nonfunctioning links so in original.>
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.06.41-242.410, AR ADC 016.06.41-242.410
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