Files > BILL/CLAIMS

name

BILL/CLAIMS

number

399

location

^DGCR(399,

description

This file contains all of the information necessary to complete a Third Party billing form. The entries in this file have matching entries in the Accounts Receivable file (430). The internal number in the AR file is the same as the internal number in the BILL/CLAIMS file. Per VHA Directive 10-93-142, this file definition should not be modified.

Fields

#	Name	Location	Type	Details	Index	Description
.01	bill number	0;1	FREE TEXT		B	This is the unique bill number assigned to this billing episode. The bill numbers are determined from entries in the AR BILL NUMBER file. New bill numbers consist of 7 characters (Example: K000001). Bill numbers for bills that have been cancelled in Integrated Billing (IB) during the process of correcting errors in the original bill, consist of 10 characters, the original bill plus a hyphen and an incremental number (Example: K000001-01).
.02	patient name(+)	0;2	POINTER	2	C	This is the name of the patient for whom this bill is being generated.
.03	event date(+)	0;3	DATE-TIME		D	This is the date on which care was originated. For inpatient episodes of care, this is the admission date. For outpatient visits, this is the date of the initial outpatient visit.
.04	location of care(+)	0;4	SET OF CODES	1:HOSPITAL (INCLUDES CLINIC) - INPT. OR OPT. 2:SKILLED NURSING (NHCU) 7:CLINIC (WHEN INDEPENDENT OR SATELLITE)		This identifies the type of facility at which care was administered.
.05	bill classification(+)	0;5	SET OF CODES	1:INPATIENT (MEDICARE PART A) 2:HUMANITARIAN EMERGENCY (INPT./MEDICARE PART B) 3:OUTPATIENT 4:HUMANITARIAN EMERGENCY (OPT./ESRD)	ABT	This code identifies the care being billed for as inpatient or outpatient.
.06	timeframe of bill(+)	0;6	SET OF CODES	1:ADMIT THRU DISCHARGE 2:INTERIM - FIRST CLAIM 3:INTERIM - CONTINUING CLAIM 4:INTERIM - LAST CLAIM 5:LATE CHARGES ONLY 6:ADJUSTMENT PRIOR CLAIM 7:REPLACEMENT PRIOR CLAIM 8:VOID/CANCEL PRIOR CLAIM O:NON-PAY/ZERO CLAIM		This code defines the frequency of this bill.
.07	rate type(+)	0;7	POINTER	399.3	AD	This identifies the type of bill.
.08	ptf entry number(+)	0;8	POINTER	45	APTF	This identifies PTF records belonging to this patient only.
.09	procedure coding method	0;9	SET OF CODES	4:CPT-4 5:HCPCS (HCFA COMMON PROCEDURE CODING SYSTEM) 9:ICD		This defines the outpatient procedure coding method utilized on this bill. If you select CPT-4, it will be changed to HCPCS automatically.
.11	who's responsible for bill?(+)	0;11	SET OF CODES	p:PATIENT i:INSURER o:OTHER		This identifies the party responsible for payment of this bill.
.13	status(+)	0;13	SET OF CODES	0:CLOSED 1:ENTERED/NOT REVIEWED 2:REQUEST MRA 3:AUTHORIZED 4:PRNT/TX 5:**NOT USED** 7:CANCELLED		This identifies the status of this billing record. That is, whether or not this record is open for editing. Current valid statuses are: 1=ENTERED/NOT REVIEWED, 2=REQUEST MRA, 3=AUTHORIZED, 4=PRNT/TX, 7=CANCELLED, 0=CLOSED Note that 5:TRANSMITTED is not currently valid Only ENTERED/NOT REVIEWED bills are editable.
.14	status date(+)	0;14	DATE-TIME			This is the date of the last status change.
.15	bill copied from	0;15	POINTER	399		If this bill was copied from another bill, then this will be the bill it was copied from. This field is automatically completed by the Copy and Cancel option.
.16	non-va discharge date	0;16	DATE-TIME			This is the discharge date for NON-VA Admissions when no associated PTF record exists. The date entered must be after the admission date and not into the future.
.17	primary bill	0;17	POINTER	399	AC	This is the initial bill that this episode is associated with. If an episode of care has more than one bill but multiple event dates, then this field can be used.
.18	sc at time of care	0;18	FREE TEXT			Was this patient Service Connected for any condition at the time the care in the bill was rendered. This field is used to correctly assign Accounts Receivable AMIS segments to this bill if it is a Reimbursable Insurance bill. Answer 'Yes' or 'No'. The default for this field is the current value in the SC PATIENT field of the patient file. If this field is left blank, the default value will be used to determine the AMIS segment.
.19	form type(+)	0;19	POINTER	353		Select the form type on which to print the bill.
.2	auto	0;20	BOOLEAN	0:NO 1:YES		True if this bill was created by the auto biller. Should only be set by the auto biller software, no manual entry.
.21	current bill payer sequence	0;21	SET OF CODES	P:PRIMARY INSURANCE S:SECONDARY INSURANCE T:TERTIARY INSURANCE A:PATIENT		This field determines the entity currently responsible for paying this bill.
.22	default division	0;22	POINTER	40.8		For rates specific to a division, this division will be used to determine the charges for all CPT's that do not have a division specified.
.24	ub-04 location of care(+)	0;24	SET OF CODES	1:HOSPITAL - INPT OR OPT (INCLUDES CLINICS) 2:SKILLED NURSING (NHCU) 3:HOME HEALTH AGENCY 7:CLINIC (ONLY INDEPENDENT/SATELITE) 8:SPEC. FACILITY HOSP/AMB SURG CTR		This field contains the code representing the location of care for a bill. This is the first digit of the 3-digit UB-04 type of bill.
.25	ub-04 bill classification(+)	0;25	POINTER	399.1		This field contains the code representing the bill classification for the bill. It is the second digit in the 3-digit UB-04 type of bill.
.26	ub-04 timeframe of bill(+)	0;26	SET OF CODES	1:ADMIT THRU DISCHARGE 2:INTERIM - 1ST CLAIM 3:INTERIM - CONTINUING CLAIM 4:INTERIM - LAST CLAIM 5:LATE CHARGES ONLY 6:ADJUSTMENT CLAIM 7:REPLACEMENT CLAIM 8:VOID/CANCEL PRIOR CLAIM O:NON-PAY/ZERO CLAIM		This field contains the code representing the timeframe of the bill value for the bill. This is the 3rd digit of the 3-digit UB-04 type of bill.
.27	bill charge type	0;27	SET OF CODES	1:INSTITUTIONAL 2:PROFESSIONAL		The service to the patient may have two components, institutional/facility and professional. If this bill only has charges for one of these components then enter that component.
1	date entered(+)	S;1	DATE-TIME		APD	This is the date on which this billing record was established.
2	entered/edited by(+)	S;2	POINTER	200		This is the user who established this billing record.
3	initial review	S;3	FREE TEXT			This allows the user to approve or disapprove the information contained in this billing record.
4	initial review date	S;4	DATE-TIME			This is the date on which this record was initially reviewed.
5	initial reviewer	S;5	POINTER	200		This is the user who performed the initial review on this billing record.
6	secondary review	S;6	FREE TEXT			This allows the user to approve or disapprove the information contained in this billing record during the secondary review stage.
7	mra requested date	S;7	DATE-TIME		APM	This is the last date for which this record requested an MRA.
8	mra requestor	S;8	POINTER	200		This is the user who requested this bill be submitted to request an MRA because MEDICARE WNR is the current insurance for the bill.
9	authorize bill generation?	S;9	FREE TEXT			This allows the user to authorize the printing/transmitting of this bill.
10	authorization date	S;10	DATE-TIME		APD3	This is the date on which this bill was authorized for printing.
11	authorizer	S;11	POINTER	200		This is the user who authorized the generation of this bill.
12	date first printed(+)	S;12	DATE-TIME		AP	This is the date on which the bill was first printed.
13	first printed by	S;13	POINTER	200		This is the user who first generated this bill.
14	date last printed	S;14	DATE-TIME			This is the date on which this bill was last printed.
15	last printed by	S;15	POINTER	200		This is the user who last printed this bill.
16	cancel bill?	S;16	FREE TEXT			This allows the user to cancel this bill.
17	date bill cancelled	S;17	DATE-TIME			This is the date on which this billing record was cancelled.
18	bill cancelled by	S;18	POINTER	200		This is the user who cancelled this bill.
19	reason cancelled(+)	S;19	FREE TEXT			This is the reason(s) why this bill was cancelled. This entry is mandatory when cancelling a bill. Enter 3-100 characters, the first character must be an alphabetic character.
20	last austin confirm date	TX;1	DATE-TIME			This is the last date/time that Austin received the bill.
21	last electronic extract date	TX;2	DATE-TIME		ALEX	This is the last time this bill was extracted to be transmitted to Austin.
22	mra recorded date	TX;3	DATE-TIME			This is the date that the MRA was recorded as being received for this bill.
24	claim mra status	TX;5	SET OF CODES	0:NO MRA NEEDED 1N:MRA NEEDED/NOT YET REQUESTED 1R:MRA REQUESTED C:VALID MRA RECEIVED A:MRA SKIPPED		This field tracks the process of obtaining an MRA for a MEDICARE primary claim.
25	request an mra?	TX;6	FREE TEXT			This field indicates that the bill is ready to send to MEDICARE for an MRA.
26	printed via edi?	TX;7	BOOLEAN	0:NO 1:YES		This field is the flag that says the bill was not transmitted electronically when the EDI contractor got the claim, but was printed at their print shop and mailed out.
27	force claim to print	TX;8	SET OF CODES	0:NO FORCED PRINT 1:FORCE LOCAL PRINT 2:*FORCE CLEARINGHOUSE PRINT		This field determines whether a claim is transmitted electronically (0) or printed locally (1).
28	force print mra secondary	TX;9	SET OF CODES	0:NO FORCED PRINT 1:MEDICARE SECONDARY FORCE LOCAL PRINT		Once the MRA is received from Medicare, the payer sequence on this claim will be incremented and this claim will become the subsequent MRA claim. If this field is set to FORCE LOCAL PRINT, then the subsequent MRA claim cannot be electronically transmitted and must be printed locally. If this field is set to NO FORCED PRINT (Default), then the subsequent MRA claim may be sent electronically to the next payer.
28.1	mra review status	TX;10	SET OF CODES	0:NOT BEING REVIEWED 1:REVIEW IN PROCESS		Select code that indicates whether this claim is under review.
29	bill cloned to	S1;1	POINTER	399		This is the Bill Number for which the new claim is being created.
30	bill cloned from	S1;2	POINTER	399		This is the bill number to which this claim is being cloned.
31	date bill cloned	S1;3	DATE-TIME			This is the date this bill was cloned.
32	bill cloned by	S1;4	POINTER	200		This is the user who cloned the claim.
33	reason cloned	S1;5	FREE TEXT			This is the reason why the old claim was cloned to a new one.
34	auto processed from claim	S1;6	POINTER	399		This claim was used to create the current claim by the commercial insurance auto-processing routines. It is system generated and uneditable by the users.
35	auto process	S1;7	SET OF CODES	1:WORKLIST 2:AUTO LOCAL PRINT 3:AUTO EDI 4:NO LONGER ON WORKLIST	CAP	The result of the commercial claim auto-processing. There are three possible outcomes of the auto-processing. The claim can automatically be sent electronically. The claim can automatically be printed locally. Finally, the claim can be added to the worklist. This claim will be changed to NO LONGER ON WORKLIST when this claim is 'worked' off either by removing, cloning, or processing the claim. This removes the claim from the active worklist but serves as an audit trail to show the result of the commercial claim auto-processing. This field is set by the system and should not be edited through Fileman.
36	auto process reason	S1;8	POINTER	350.8		This is the reason that the claim failed auto-processing and was put on the worklist. This is system generated. Do not edit through Fileman.
37	removed from worklist by	S1;9	POINTER	200		This is the user who removed the Claim from the COB worklist. Set by the system automatically. Don't edit through Fileman.
38	removed from worklist how	UF32;4	SET OF CODES	RM:REMOVE ACTION PC:PROCESS COB ACTION CL:CLONE ACTION CA:CANCELLED ACTION CR:CORRECTED ACTION		This is the action which removed this claim from the COB worklist. Set by the system automatically. Don't edit through Fileman.
39	removed from worklist date	UF32;5	DATE-TIME			This is the date/time the claim was removed from the COB management worklist worklist. Set automatically. Don't edit through Fileman.
40	condition code	CC;0	MULTIPLE	399.04		This identifies the condition(s) relating to this bill that may affect payer processing.
41	occurrence code	OC;0	MULTIPLE	399.041		This identifies the significant event(s) relating to this bill that may affect payer processing.
42	revenue code	RC;0	MULTIPLE	399.042		This identifies specific accommodation(s), ancillary service(s) or billing calculation(s).
43	op visits date(s)	OP;0	MULTIPLE	399.043		This identifies the outpatient visit date(s) which are included on this bill.
44	reason(s) disapproved-initial	D1;0	MULTIPLE	399.044		This defines the reason(s) why this billing record was disapproved during the initial review phase.
45	reason(s) disapproved-second	D2;0	MULTIPLE	399.045		This defines the reason(s) why this billing record was disapproved during the secondary review phase.
46	returned log date/time	R;0	MULTIPLE	399.046		This field provides the audit trail of who edited a bill after is has been returned from being Audited for correction by the approving service. Data in this field is automatically entered by the system whenever a returned bill is edited and/or returned to fiscal.
47	value code	CV;0	MULTIPLE	399.047
48	other care	OT;0	MULTIPLE	399.048		Allows definition of the type of care to be other than the standard inpatient or outpatient.
51	*cpt procedure code (1)	C;1	POINTER	81		This is a CPT outpatient procedure code. This field has been marked for deletion 11/4/91.
52	*cpt procedure code (2)	C;2	POINTER	81		This is a CPT outpatient procedure code. This field has been marked for deletion on 11/4/91.
53	*cpt procedure code (3)	C;3	POINTER	81		This is a CPT outpatient procedure code. This field has been marked for deletion on 11/4/91.
54	*icd procedure code (1)	C;4	POINTER	80.1		This is an ICD outpatient procedure code. This field is marked for deletion on 11/4/91.
55	*icd procedure code (2)	C;5	POINTER	80.1		This is an ICD outpatient procedure code. This field is marked of deletion on 11/4/91.
56	*icd procedure code (3)	C;6	POINTER	80.1		This is an ICD outpatient procedure code. This field is marked for deletion on 11/4/91.
57	*hcfa procedure code (1)	C;7	POINTER	81		This is a HCFA outpatient procedure code. This field is marked for deletion on 11/4/91.
58	*hcfa procedure code (2)	C;8	POINTER	81		This is a HCFA outpatient procedure code. This field has been marked for deletion on 11/4/91.
59	*hcfa procedure code (3)	C;9	POINTER	81		This is a HCFA outpatient procedure code. This field has been marked for deletion on 11/4/91.
60	outpatient diagnosis	C;10	FREE TEXT			The outpatient diagnosis is selectable from the ICD DIAGNOSIS file.
61	*procdedure date (1)(+)	C;11	DATE-TIME			This is the date on which the first procedure associated with this billing episode occurred. This field has been marked for deletion on 11/4/91.
62	*procedure date (2)(+)	C;12	DATE-TIME			This is the date on which the second procedure associated with this billing episode occurred. This field has been marked for deletion on 11/4/91.
63	*procedure date (3)(+)	C;13	DATE-TIME			This is the date on which the third procedure associated with this billing episode occurred. This field has been marked for deletion on 11/4/91.
65	*icd diagnosis code (2)	C;15	POINTER	80		This is the second ICD diagnosis code associated with this billing episode.
66	*icd diagnosis code (3)	C;16	POINTER	80		This is the third ICD diagnosis code associated with this billing episode.
67	*icd diagnosis code (4)	C;17	POINTER	80		This is the fourth ICD diagnosis code associated with this billing episode.
68	*icd diagnosis code (5)	C;18	POINTER	80		This is the fifth ICD diagnosis code associated with this billing episode.
77	mra request claim comments	TXC;0	MULTIPLE	399.077		This multiple structure is available only for those claims in a status of 2 - REQUEST MRA. This will allow the users to enter comments either in TPJI or in the MRA worklist that pertain to this claim during the time the MRA request claim is sent to Medicare and before the MRA secondary claim is authorized to the secondary payer. Once entered, comments may not be edited or deleted by the users.
78	eob claim comments	TXC2;0	MULTIPLE	399.078		This multiple structure is available only for those claims on the COB Management Worklist. This will allow the users to view comments either in TPJI or in the COB worklist. Once entered, comments may not be edited or deleted by the users.
101	primary insurance carrier(+)	M;1	POINTER	36		This is the name of the insurance carrier to which this bill is to be sent. This is from the entries in this patient's file of insurance companies.
102	secondary insurance carrier	M;2	POINTER	36		This is the name of the secondary insurance carrier from which the provider might expect some payment for this bill.
103	tertiary insurance carrier	M;3	POINTER	36		This is the name of the tertiary insurance carrier from which the provider might expect some payment for this bill.
104	mailing address name	M;4	FREE TEXT			This is the name of the party to whom this bill is to be sent.
105	mailing address street	M;5	FREE TEXT			This is the street address to which this bill is to be sent.
106	mailing address street2	M;6	FREE TEXT			This is the street address to which this bill is to be sent.
107	mailing address city	M;7	FREE TEXT			This is the city to which this bill is to be sent.
108	mailing address state	M;8	POINTER	5		This is the state to which this bill is to be sent.
109	mailing address zip code	M;9	FREE TEXT			This is the 5-digit or 9-digit zip code to which this bill is to be sent.
110	*patient short mailing address(+)	M;10	FREE TEXT			This is the 1-47 character patient mailing address that will print in block 11 on the UB-82 form and block 13 on the UB-92. The computer will try to calculate this. If the length of all the patient address fields is longer than 47 characters you will need to abbreviate this in order to get it to print in this block. This field is marked for deletion and can be deleted 11/23/2008.
111	responsible institution(+)	M;11	POINTER	4		This is the name of the institution or organization responsible for payment of this bill.
112	primary insurance policy	M;12	FREE TEXT			The policy to be billed for this episode of care.
113	secondary insurance policy	M;13	FREE TEXT			The secondary policy to be billed for this episode of care.
114	tertiary insurance policy	M;14	FREE TEXT			The tertiary policy to be billed for this episode of care.
121	mailing address street3	M1;1	FREE TEXT			This is the street address to which this bill is to be sent.
122	primary provider #	M1;2	FREE TEXT			This is the number assigned to the provider by the primary payer. Printed in Form Locator 57 for the Primary Insurance Carrier on the UB-04.
123	secondary provider #	M1;3	FREE TEXT			This is the number assigned to the provider by the secondary payer. Printed in Form Locator 57 for the Secondary Insurance Carrier on the UB-04.
124	tertiary provider #	M1;4	FREE TEXT			This is the number assigned to the provider by the tertiary payer. Printed in Form Locator 57 for the Tertiary Insurance Carrier on the UB-04.
125	primary bill #	M1;5	POINTER	399		This is the bill to the Primary Payer for the episode(s) on this bill.
126	secondary bill #	M1;6	POINTER	399		This is the bill to the Secondary Payer for the episode(s) on this bill.
127	tertiary bill #	M1;7	POINTER	399		This is the bill to the Tertiary Payer for the episode(s) on this bill.
128	primary id qualifier	M1;10	POINTER	355.97		This is the qualifier for PRIMARY PROVIDER #.
129	secondary id qualifier	M1;11	POINTER	355.97		This is the qualifier for the SECONDARY PROVIDER #.
130	tertiary id qualifier	M1;12	POINTER	355.97		This is the qualifier for the TERTIARY PROVIDER #.
135	bill payer carrier	MP;1	POINTER	36		This is the Insurance Carrier responsible for the bill. This may only be set to the Carrier assigned as Primary, Secondary, or Tertiary carrier that corresponds to the Payer Sequence.
136	bill payer policy	MP;2	FREE TEXT			This is the policy responsible for this bill. This may only be set to the policy assigned as Primary, Secondary, or Tertiary policy that corresponds to the Payer Sequence.
151	statement covers from(+)	U;1	DATE-TIME			This is the beginning service date of the period covered by this bill. The date range for inpatient interim bills should not be overlapped.
152	statement covers to(+)	U;2	DATE-TIME			This is the ending service date of the period covered by this bill. The date range for inpatient interim bills should not be overlapped.
153	power of attorney completed?(+)	U;3	FREE TEXT			This identifies whether or not the power of attorney forms (if necessary) have been signed.
154	whose employment info.?(+)	U;4	SET OF CODES	p:PATIENT s:SPOUSE		This indicates whether the employment information give applies to the patient or to the patient's spouse.
155	is this a sensitive record?(+)	U;5	FREE TEXT			This indicates whether or not this record contains information pertaining to, but not limited to, drugs, alcohol, or sickle cell anemia, and if so, allows the user to identify this record as "sensitive".
156	assignment of benefits(+)	U;6	FREE TEXT			This indicates whether or not a third party is authorized to pay the provider for services covered by this bill.
157	r.o.i. form(s) completed?	U;7	FREE TEXT			This allows the user to indicate if the Release of Information forms (if necessary) have been signed.
158	type of admission	U;8	SET OF CODES	1:EMERGENCY 2:URGENT 3:ELECTIVE 4:NEWBORN 5:TRAUMA 9:INFORMATION NOT AVAILABLE		Enter the Priority/Type of this admission.
159	source of admission	U;9	SET OF CODES	1:PHYSICIAN REFERRAL 2:CLINIC REFERRAL 3:HMO REFERRAL 4:TRANSFER FROM HOSPITAL 5:TRANSFER FROM SKILLED NURSING FAC. 6:TRANSFER FROM OTHER HEALTH CARE FAC. 7:EMERGENCY ROOM 8:COURT/LAW ENFORCEMENT 9:INFO NOT AVAILABLE		This indicates the source of this admission or how an outpatient came to be treated at the facility.
159.5	non-ptf admission hour	U;20	FREE TEXT			This is the actual hour the patient was admitted for non-PTF related bills.
160	accident hour	U;10	FREE TEXT			This indicates the hour at which an accident occurred if this episode of care is related to an accident.
161	discharge bedsection	U;11	POINTER	399.1		This is the bedsection from which this patient was discharged.
162	discharge status	U;12	POINTER	399.1		This is the patient status as of the statement covers through date.
163	treatment authorization code	U;13	FREE TEXT			This indicates that the treatment covered by this bill has been authorized by the primary payer. On the CMS-1500 this is box 23, PRIOR AUTHORIZATION NUMBER. On the UB-04, this is reported in FL63.
164	bc/bs provider #(+)	U;14	FREE TEXT			This is the Blue Cross/Blue Shield Provider Number for this billing episode.
165	length of stay	U;15	FREE TEXT			This defines the length of stay in days for this inpatient episode excluding pass, AA, and UA days.
166	unable to work from	U;16	DATE-TIME			Enter the beginning date for the period of time that the patient could not work due to the condition for which this claim is being submitted. Printed on the CMS-1500.
167	unable to work to	U;17	DATE-TIME			This is the ending date of the period of time during which the patient was unable to work due to the condition for which this claim is being submitted. Used on the CMS-1500.
168	*place of service	U;18	POINTER	353.1		This indicates the Place of Service, used on the HCFA 1500. Not used after IB v1.5, replaced by PLACE OF SERVICE (304,8) associated with a specific procedure. Marked for deletion 6/11/93.
169	*type of service	U;19	POINTER	353.2		Code indicating the Type of Service preformed. Used on the HCFA 1500. Not used after IB v1.5, replaced by TYPE OF SERVICE (304,9) associated with a specific procedure. Marked for deletion 6/11/93.
170	pps	U1;15	POINTER	80.2		Accept the default Discharge DRG as the PPS value or enter another DRG from the PTF file or from the DRG file.
201	total charges	U1;1	NUMERIC			This is the total amount of the revenue code charges for this bill.
202	offset amount	U1;2	NUMERIC			This is the dollar amount which is to be subtracted from the total charges on this bill. Offset includes, but is not limited to, co-payments, credits, and deductibles.
203	offset description	U1;3	FREE TEXT			This defines the reason for offset amount. Maximum length is 24 characters.
204	*ub82 form locator 2	U1;4	FREE TEXT			This allows the user to enter information which will appear in form locator 2 on the UB-82 form. This field is marked for deletion and can be deleted 11/23/2008.
205	*form locator 9	U1;5	FREE TEXT			This allows the user to enter information which will appear in form locator 9 on the UB-82 form. This field is marked for deletion and can be deleted 11/23/2008.
206	*form locator 27	U1;6	FREE TEXT			This allows the user to enter information will will appear in form locator 27 on the UB-82 form. This field is marked for deletion and can be deleted 11/23/2008.
207	*form locator 45	U1;7	FREE TEXT			This allows the user to enter information which will appear in form locator 45 on the UB-82 form. This field is marked for deletion and can be deleted 11/23/2008.
208	*bill comment	U1;8	FREE TEXT			This field is not used after IB patch 349. The new remarks field for FL-80 on the UB-04 is BILL REMARKS (field#402).
209	*fiscal year 1(+)	U1;9	FREE TEXT			This defines the first fiscal year with which this bill is associated. OBSOLETE AS OF PATCH IB*2*137 -- 2001
210	*fy 1 charges(+)	U1;10	NUMERIC			These are the charges incurred during the first fiscal year associated with this bill. OBSOLETE AS OF PATCH IB*2*137 -- 2001
211	*fiscal year 2	U1;11	FREE TEXT			This is the second fiscal year with which this bill is associated. OBSOLETE AS OF PATCH IB*2*137 -- 2001
212	*fy 2 charges	U1;12	NUMERIC			These are the charges incurred during the second fiscal year associated with this bill. OBSOLETE AS OF PATCH IB*2*137 -- 2001
213	*form locator 92	U1;13	FREE TEXT			This is the Attending Physician ID (UPIN) and is printed on the UB-82 in form locator 92 and form locator 82 on the UB-92. This field will be loaded with the ATTENDING PHYSICIAN ID code required by the primary insurer, if that insurer has a code defined. This field is marked for deletion and can be deleted 11/23/2008.
214	*form locator 93	U1;14	FREE TEXT			Enter the 'Other Physician ID'. The name and/or number of the licensed physician other than the attending physician or what the primary insurer requires in this field on the form. Will print in form locator 93 on the UB-82 and form locator 83 on the UB-92.
215	admitting diagnosis	U2;1	POINTER	80		The ICD-9 diagnosis code provided at the time of admission as stated by the physician. The admitting diagnosis code will be printed in Form Locator 69 on the UB-04.
216	covered days	U2;2	NUMERIC			The number of days covered by the primary payer, as qualified by the payer organization.
217	non-covered days	U2;3	NUMERIC			Days of care not covered by the primary payer.
218	primary prior payment	U2;4	NUMERIC			This is the amount the primary insurance has already paid on this bill.
219	secondary prior payment	U2;5	NUMERIC			This is the amount the secondary insurance has already paid on this bill.
220	tertiary prior payment	U2;6	NUMERIC			This is the amount the tertiary insurance has already paid on this bill.
221	co-insurance days	U2;7	NUMERIC			This is the # of days.
222	provider	PRV;0	MULTIPLE	399.0222
230	secondary authorization code	U2;8	FREE TEXT			This indicates that the treatment covered by this bill has been authorized by the secondary payer. On the CMS-1500 this is box 23, PRIOR AUTHORIZATION NUMBER. On the UB-04, this is reported in FL63.
231	tertiary authorization code	U2;9	FREE TEXT			This indicates that the treatment covered by this bill has been authorized by the tertiary payer. On the CMS-1500 this is box 23, PRIOR AUTHORIZATION NUMBER. On the UB-04, this is reported in FL63.
232	non-va facility	U2;10	POINTER	355.93		The is the name of the non-VA or outside VA facility where the services were rendered.
233	non-va care type	U2;11	SET OF CODES	1:FEE BASIS, NON-LAB 2:FEE BASIS, LAB 3:NON-FEE BASIS, NON-LAB 4:NON-FEE BASIS, LAB		This is the code that identifies if the care given was fee basis lab, fee basis non-lab, or non-fee basis care.
234	non-va care id #	U2;12	FREE TEXT			This is the id number to be reported on the bill for the non-VA facility where care was provided. For a lab, this should be the CLIA #
235	lab clia number	U2;13	FREE TEXT			Enter the CLIA number for the VA Division if the service was performed by the VA. Enter the CLIA number for the Other Facility if the service was performed by a non-VA facility. You can define a CLIA number as a secondary ID for a non-VA Facility through Provider ID Maint. If you enter a CLIA number here that is not defined in Provider ID Maint (non-VA) or the Institution file (VA), it will be sent with this claim only.
236	homebound	U2;14	BOOLEAN	0:NO 1:YES		This is to indicate that the patient is homebound or institutionalized. Refer to MEDICARE regulations on when to use this field.
237	date last seen	U2;15	DATE-TIME			This is the date a patient was last seen. Refer to MEDICARE regulations on when to use this field.
238	special program indicator	U2;16	SET OF CODES	01:EPSDT/CHAP 02:Phys Handicapped Children Program 03:Special Fed Funding 05:Disability 07:Induced Abortion - Danger to Life 08:Induced Abortion - Rape or Incest 09:2nd Opinion/Surgery		This is the Special Program with which a claim is associated. Refer to MEDICARE regulations to decide when to use this field.
239	primary emc id care unit	U2;17	FREE TEXT			This is the data value needed to allow the system to match the attending/rendering provider with the correct EMC id # for the primary ins co.
240	secondary emc id care unit	U2;18	FREE TEXT			This is the data value needed to allow the system to match the attending/rendering provider with the correct EMC id # for the secondary ins co.
241	tertiary emc id care unit	U2;19	FREE TEXT			This is the data value needed to allow the system to match the attending/rendering provider with the correct EMC id # for the tertiary ins co.
242	mammography cert number	U3;1	FREE TEXT			Enter the Mammography Certification number for the VAMC if the service was performed by the VA. Enter the Mammography Certification number for the Other Facility if the service was performed by a non-VA facility. You can define a Mammography Certification number for a non-VA Facility through Provider ID Maint. If you enter a Mammography Certification number here that is not defined in Provider ID Maint (non-VA) or the Institution file (VA), it will be sent with this claim only.
243	service facility taxonomy	U3;2	POINTER	8932.1		This field contains the organizational taxonomy code for the Service Facility. You may override the default taxonomy code here.
244	non-va facility taxonomy	U3;3	POINTER	8932.1
245	last xray date	U3;4	DATE-TIME			If an Xray was used to demonstrate a subluxation of the spine, enter the date of the last Xray. If an Xray date is entered, it will automatically print on CMS-1500.
246	date of initial treatment	U3;5	DATE-TIME			Date on which these treatments were started.
247	date of acute manifestation	U3;6	DATE-TIME			If the Patient's Condition Code equals Acute Condition or Acute Manifestation of a Chronic Condition, you must enter the date on which the acute condition started.
248	patient condition code	U3;7	SET OF CODES	A:Acute Condition C:Chronic Condition D:Non-acute Condition E:Non-Life Threatening F:Routine G:Symptomatic M:Acute Manifestation of a Chronic Condition		Enter one of the following required codes;
249	prv diagnosis (1)	U3;8	POINTER	80		This is the first PRV diagnosis.
250	prv diagnosis (2)	U3;9	POINTER	80		This is the second PRV diagnosis.
251	prv diagnosis (3)	U3;10	POINTER	80		This is the third PRV diagnosis.
252	billing provider taxonomy	U3;11	POINTER	8932.1		This field contains the organizational taxonomy code for the Billing Provider. You may override the default taxonomy code here.
253	primary referral number	UF32;1	FREE TEXT			This is the primary referral number assigned to the insurance.
254	secondary referral number	UF32;2	FREE TEXT			This is the secondary referral number assigned to the insurance.
255	tertiary referral number	UF32;3	FREE TEXT			This is the tertiary referral number assigned to the insurance.
260	cob total non-covered amount	U4;1	NUMERIC			This is a dollar amount that must equal the Total Claim Charge Amount. Required when the current payer allows providers to bypass claim submission to the otherwise prior payer (example: Medicare secondary with no MRA).
261	property/casualty claim number	U4;2	FREE TEXT			This is a payer-assigned claim number for a property and casualty claim.
262	prop/cas date of 1st contact	U4;3	DATE-TIME			This is the date the patient first consulted the service provider for this property and casualty related condition. Required when state mandated.
263	disability start date	U4;4	DATE-TIME			This is the Disability start date. Cannot be a future date, and cannot be after Disability end date.
264	disability end date	U4;5	DATE-TIME			This is the Disability stop date. Future dates are not allowed and stop date cannot be before start date.
266	primary surgical proc code	U4;7	POINTER	81		This is a primary HCPCS surgical code when anesthesiology services are being billed and the payment of the claim is dependent on provision of surgical codes.
267	secondary surgical proc code	U4;8	POINTER	81		This is a secondary HCPCS surgical code when anesthesiology services are being billed and the payment of the claim is dependent on provision of surgical codes.
268	property/casualty contact name	U4;9	FREE TEXT			This is the name of the person to be contacted regarding this Property and Casualty claim if different from the Patient/Subscriber.
269	prop/cas communication number	U4;10	NUMERIC			Enter the area code and phone number for the person to be contacted regarding this Property and Casualty claim.
269.1	prop/cas extension number	U4;11	NUMERIC			This is the extension number for the person to be contacted regarding this Property and Casualty claim.
271	ambulance p/u address 1	U5;2	FREE TEXT			This is line one of the street address where the patient was picked up. Required for ambulance transportation.
272	ambulance p/u address 2	U5;3	FREE TEXT			This is line two of the address where the patient was picked up.
273	ambulance p/u city	U5;4	FREE TEXT			This is the City where the patient was picked up. Required for ambulance transportation.
274	ambulance p/u state	U5;5	POINTER	5		This is the State where the patient was picked up. Required for ambulance transportation.
275	ambulance p/u zip	U5;6	FREE TEXT			This is the Zip code of the location where the patient was picked up. Required for ambulance transportation.
276	ambulance d/o location	U6;1	FREE TEXT			This is the name of the location where the patient was dropped off, if it is known.
277	ambulance d/o address 1	U6;2	FREE TEXT			This is line one of the street address where the patient was dropped off. Required for ambulance transportation.
278	ambulance d/o address 2	U6;3	FREE TEXT			This is line two of the address where the patient was dropped off.
279	ambulance d/o city	U6;4	FREE TEXT			This is the City where the patient was dropped off. Required for ambulance transportation.
280	ambulance d/o state	U6;5	POINTER	5		This is the State where the patient was dropped off. Required for ambulance transportation.
281	ambulance d/o zip	U6;6	FREE TEXT			This is the Zip code of the location where the patient was dropped off. Required for ambulance transportation.
282	assumed care date	U4;13	DATE-TIME			This is the date on which the provider on this claim assumed the post-operative care associated with this claim. Cannot be a future date or greater than the relinquished care date.
283	relinquished care date	U4;14	DATE-TIME			This is the date on which the provider on this claim relinquished the post-operative care associated with this claim.
284	attachment control number	U8;1	FREE TEXT			This is an Attachment Control Number (alphanumeric) that can be used to identify the documentation that will provide additional information for this claim. This applies to the entire claim.
285	attachment report type	U8;2	POINTER	353.3		This is a Report Type to describe the type of documentation that will provide additional information for this claim. This applies to the entire claim.
286	attachment report trans code	U8;3	SET OF CODES	AA:Available on Request at Provider Site BM:By Mail EL:Electronically Only EM:E-Mail FT:File Transfer FX:By Fax		This is the code for the Attachment Transmission Method. This applies to the entire claim.
287	patient weight (lb)	U7;1	NUMERIC			This is a whole number for the patient's weight.
288	transport reason code	U7;2	POINTER	353.4		This is the code indicating the reason for transport.
289	ambulance transport distance	U7;3	NUMERIC			This is a whole number for the distance traveled during transport.
290	round trip purpose description	U7;4	FREE TEXT			This is a free text explanation of the purpose of the R/T service.
291	stretcher purpose description	U7;5	FREE TEXT			This is a free text explanation of why a stretcher was used.
292	ambulance condition indicator	U9;0	MULTIPLE	399.0292		This allows up to five patient condition indicators to describe the patient during ambulance pickup, transport, and drop off.
301	primary node(+)	I1;E1,240	FREE TEXT			This is the information pertaining to the primary insurance carrier which is associated with this bill.
302	secondary node(+)	I2;E1,240	FREE TEXT			This is the information pertaining to the secondary insurance carrier which is associated with this bill.
303	tertiary node(+)	I3;E1,240	FREE TEXT			This is the information pertaining to the tertiary insurance carrier associated with this bill.
304	procedures	CP;0	MULTIPLE	399.0304		These are ICD or CPT procedures that are associated with this bill.
371	primary node 7(+)	I17;E1,240	FREE TEXT			This is addl. information pertaining to the primary insurance carrier associated with this bill. It is equal to the 7 node of the INSURANCE TYPE sub-file of the PATIENT file.
372	secondary node 7(+)	I27;E1,240	FREE TEXT			This is addl. information pertaining to the secondary insurance carrier associated with this bill. It is equal to the 7 node of the INSURANCE TYPE sub-file of the PATIENT file.
373	tertiary node 7(+)	I37;E1,240	FREE TEXT			This is addl. information pertaining to the tertiary insurance carrier associated with this bill. It is equal to the 7 node of the INSURANCE TYPE sub-file of the PATIENT file.
400	block 31	UF2;1	FREE TEXT			Entry will be printed in block 31 of the CMS-1500. This block is 3 lines of 21 characters each. Set up for the physicians name and number.
402	bill remarks	UF2;3	FREE TEXT			Enter up to 80 characters of free text which will print in FL-80. FL-80 on the UB-04 claim form is a 4-line box. Line 1 can hold a maximum of 19 characters after a mandatory 5 character indentation. Lines 2-4 can hold a maximum of 24 characters each. The display of these remarks on billing screen 8 is exactly how the remarks will appear on the printed claim form.
453	form locator 64a	UF3;4	FREE TEXT			Form Locator 64A on the UB-04. This field is nationally reserved on adjustment/replacement type bills for the Internal Control Number (ICN)/Document Control Number (DCN) assigned to the original bill by the primary payer.
454	form locator 64b	UF3;5	FREE TEXT			Form Locator 64B on the UB-04. This field is nationally reserved on adjustment/replacement type bills for the Internal Control Number (ICN)/Document Control Number (DCN) assigned to the original bill by the secondary payer.
455	form locator 64c	UF3;6	FREE TEXT			Form Locator 64C on the UB-04. This field is nationally reserved on adjustment/replacement type bills for the Internal Control Number (ICN)/Document Control Number (DCN) assigned to the original bill by the tertiary payer.
457	*form locator 57	UF31;1	FREE TEXT			Unlabled Form Locator 57 on the UB-92. This field is marked for deletion and can be deleted 11/23/2008.
458	*form locator 78	UF31;2	FREE TEXT			Printed in Form Locator 78 on the UB-92. If more than 3 characters are entered this will be printed on two lines. This field is marked for deletion and can be deleted 11/23/2008.
459	form loc 19-unspecified data	UF31;3	FREE TEXT			This is an 71 character free text field that will print in Box 19 of the CMS-1500. Use this field to enter additional Payer required IDs in the format of: QualifierID number<3 spaces>QualifierID number.
460	ecme number	M1;8	FREE TEXT		AG	This is the reference number back to the ECME transaction to identify bills created electronically by the ECME/Pharmacy NCPDP process.
461	ecme approval	M1;9	FREE TEXT			This is the approval for payment received from the FI for ECME electronically processed claims.
471	primary insurance hpid	M1;13	NUMERIC			This field is the HPID to be sent for the primary insurer on this claim.
472	secondary insurance hpid	M1;14	NUMERIC			This field is the HPID to be sent for the secondary insurer on this claim.
473	tertiary insurance hpid	M1;15	NUMERIC			This field is the HPID to be sent for the tertiary insurer on this claim.