Attachment D: Currently Approved UB-04 Data Elements
FL |
Description |
FL01 |
[Billing Provider Name] |
FL01 |
[Billing Provider Street Address] |
FL01 |
[Billing Provider City, State, Zip] |
FL01 |
[Billing Provider Telephone, Fax, Country Code] |
FL02 |
[Billing Provider’s Designated Pay-to Name] |
FL02 |
[Billing Provider’s Designated Pay-to Address] |
FL02 |
[Billing Provider’s Designated Pay-to City, State] |
FL02 |
[Billing Provider’s Designated Pay-to ID] |
FL03a |
Patient Control Number |
FL03b |
Medical/Health Record Number |
FL04 |
Type of Bill |
FL05 |
Federal Tax Number |
FL05 |
Federal Tax Number |
FL06 |
Statement Covers Period - From/Through |
FL07 |
Unlabeled |
FL07 |
Unlabeled |
FL08 |
Patient Name/ID |
FL08 |
Patient Name |
FL09 |
Patient Address - Street |
FL09 |
Patient Address - City |
FL09 |
Patient Address - State |
FL09 |
Patient Address - ZIP |
FL09 |
Patient Address - Country Code |
FL10 |
Patient Birthdate |
FL11 |
Patient Sex |
FL12 |
Admission/Start of Care Date |
FL13 |
Admission Hour |
FL14 |
Priority (Type) of Admission or Visit |
FL15 |
Point of Origin for Admission or Visit |
FL16 |
Discharge Hour |
FL17 |
Patient Discharge Status |
FL18 |
Condition Code |
FL19 |
Condition Code |
FL20 |
Condition Code |
FL21 |
Condition Code |
FL22 |
Condition Code |
FL23 |
Condition Code |
FL24 |
Condition Code |
FL25 |
Condition Code |
FL26 |
Condition Code |
FL27 |
Condition Code |
FL28 |
Condition Code |
FL29 |
Accident State |
FL30 |
Unlabeled |
FL30 |
Unlabeled |
FL31 |
Occurrence Code/Date |
FL31 |
Occurrence Code/Date |
FL32 |
Occurrence Code/Date |
FL32 |
Occurrence Code/Date |
FL33 |
Occurrence Code/Date |
FL33 |
Occurrence Code/Date |
FL34 |
Occurrence Code/Date |
FL34 |
Occurrence Code/Date |
FL35 |
Occurrence Span Code/From/Through |
FL35 |
Occurrence Span Code/From/Through |
FL36 |
Occurrence Span Code/From/Through |
FL36 |
Occurrence Span Code/From/Through |
FL37 |
Unlabeled |
FL37 |
Unlabeled |
FL38 |
Responsible Party Name/Address |
FL38 |
Responsible Party Name/Address |
FL38 |
Responsible Party Name/Address |
FL38 |
Responsible Party Name/Address |
FL38 |
Responsible Party Name/Address |
FL39 |
Value Code |
FL39 |
Value Code Amount |
FL39 |
Value Code |
FL39 |
Value Code Amount |
FL39 |
Value Code |
FL39 |
Value Code Amount |
FL39 |
Value Code |
FL39 |
Value Code Amount |
FL40 |
Value Code |
FL40 |
Value Code Amount |
FL40 |
Value Code |
FL40 |
Value Code Amount |
FL40 |
Value Code |
FL40 |
Value Code Amount |
FL40 |
Value Code |
FL40 |
Value Code Amount |
FL41 |
Value Code |
FL41 |
Value Code Amount |
FL41 |
Value Code |
FL41 |
Value Code Amount |
FL41 |
Value Code |
FL41 |
Value Code Amount |
FL41 |
Value Code |
FL41 |
Value Code Amount |
FL42 |
Revenue Codes |
FL43 |
Revenue Code Description/IDE Number/Medicaid Drug rebate |
FL44 |
HCPCS/Accommodation Rates/HIPPS Rate Codes |
FL45 |
Service Dates |
FL46 |
Service Units |
FL47 |
Total Charges |
FL48 |
Non-Covered Charges |
FL49 |
Unlabeled |
FL50 |
Payer Identification - Primary |
FL50 |
Payer Identification - Secondary |
FL50 |
Payer Identification - Tertiary |
FL51 |
Health Plan ID |
FL51 |
Health Plan ID |
FL51 |
Health Plan ID |
FL52 |
Release of Information - Primary |
FL52 |
Release of Information - Secondary |
FL52 |
Release of Information - Tertiary |
FL53 |
Assignment of Benefits - Primary |
FL53 |
Assignment of Benefits - Secondary |
FL53 |
Assignment of Benefits - Tertiary |
FL54 |
Prior Payments - Primary |
FL54 |
Prior Payments - Secondary |
FL54 |
Prior Payments - Tertiary |
FL55 |
Estimated Amount Due - Primary |
FL55 |
Estimated Amount Due - Secondary |
FL55 |
Estimated Amount Due - Tertiary |
FL56 |
NPI – Billing Provider |
FL57 |
Other Provider ID |
FL57 |
Other Provider ID |
FL57 |
Other Provider ID |
FL58 |
Insured’s Name - Primary |
FL58 |
Insured's Name - Secondary |
FL58 |
Insured's Name -Tertiary |
FL59 |
Patient’s Relationship - Primary |
FL59 |
Patient's Relationship - Secondary |
FL59 |
Patient's Relationship - Tertiary |
FL60 |
Insured’s Unique ID-Primary |
FL60 |
Insured's Unique ID - Secondary |
FL60 |
Insured's Unique ID - Tertiary |
FL61 |
Insurance Group Name - Primary |
FL61 |
Insurance Group Name - Secondary |
FL61 |
Insurance Group Name -Tertiary |
FL62 |
Insurance Group No. - Primary |
FL62 |
Insurance Group No. - Secondary |
FL62 |
Insurance Group No. - Tertiary |
FL63 |
Treatment Authorization Codes - Primary |
FL63 |
Treatment Authorization Code - Secondary |
FL63 |
Treatment Authorization Code - Tertiary |
FL64 |
Document Control Number (DCN) |
FL64 |
Document Control Number (DCN) |
FL64 |
Document Control Number (DCN) |
FL65 |
Employer Name (of the insured) - Primary |
FL65 |
Employer Name (of the insured) - Secondary |
FL65 |
Employer Name (of the insured) - Tertiary |
FL66 |
Diagnosis and Procedure Code Qualifier (ICD Version Indicator) |
FL67 |
Principal Diagnosis Code and Present on Admission (POA) Indicator |
FL67A |
Other Diagnosis and POA Indicator |
FL67B |
Other Diagnosis and POA Indicator |
FL67C |
Other Diagnosis and POA Indicator |
FL67D |
Other Diagnosis and POA Indicator |
FL67E |
Other Diagnosis and POA Indicator |
FL67F |
Other Diagnosis and POA Indicator |
FL67G |
Other Diagnosis and POA Indicator |
FL67H |
Other Diagnosis and POA Indicator |
FL67I |
Other Diagnosis and POA Indicator |
FL67J |
Other Diagnosis and POA Indicator |
FL67K |
Other Diagnosis and POA Indicator |
FL67L |
Other Diagnosis and POA Indicator |
FL67M |
Other Diagnosis and POA Indicator |
FL67N |
Other Diagnosis and POA Indicator |
FL67O |
Other Diagnosis and POA Indicator |
FL67P |
Other Diagnosis and POA Indicator |
FL67Q |
Other Diagnosis and POA Indicator |
FL68 |
Unlabeled |
FL68 |
Unlabeled |
L69 |
Admitting Diagnosis Code |
FL70a |
Patient Reason for Visit Code |
FL70b |
Patient Reason for Visit Code |
FL70c |
Patient Reason for Visit |
FL71 |
Prospective Payment System (PPS) Code |
FL72a |
External Cause of Injury Code and POA Indicator |
FL72b |
External Cause of Injury Code and POA Indicator |
FL72c |
External Cause of Injury Code and POA |
FL73 |
Unlabeled |
FL74 |
Principal Procedure Code/Date |
FL74a |
Other Procedure Code/Date |
FL74b |
Other Procedure Code/Date |
FL74c |
Other Procedure Code/Date |
FL74d |
Other Procedure Code/Date |
FL74e |
Other Procedure Code/Date |
FL75 |
Unlabeled |
FL75 |
Unlabeled |
FL75 |
Unlabeled |
FL75 |
Unlabeled |
FL76 |
Attending Provider - NPI/QUAL/ID |
FL76 |
Attending Provider – Last/First |
FL77 |
Operating Physician - NPI/QUAL/ID |
FL77 |
Operating Physician - Last/First |
FL78 |
Other Provider - QUAL/NPI/QUAL/ID |
FL78 |
Other Provider - Last/First |
FL79 |
Other Provider - QUAL/NPI/QUAL/ID |
FL79 |
Other Provider - Last/First |
FL80 |
Remarks |
FL80 |
Remarks |
FL80 |
Remarks |
FL80 |
Remarks |
FL81 |
Code-Code - QUAL/CODE/VALUE |
FL81 |
Code-Code - QUAL/CODE/VALUE |
FL81 |
Code-Code - QUAL/CODE/VALUE |
FL81 |
Code-Code - QUAL/CODE/VALUE |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Clarice brown |
File Modified | 0000-00-00 |
File Created | 2021-11-05 |