Attachment C - UB-92 Claim Form Example (pdf)

UB-92 Claim Form Example (Textual Description Below)

 Image was clipped at the red line for reducing size.

Textual Description:

  1. Provider Name and Address
    Enter provider's name, address, zip code and phone number. Use this block to enter your Regence BCBSO or Regence HMO Oregon provider billing number.
  2. Leave Blank
  3. Patient Control Number
    Enter patient's control number or patient account number.
  4. Type of Bill (TOB) Enter type of bill code.
    1. Valid type of bill codes:
      • Hospital - Inpatient
        11X 12X 18X
      • Hospital - Outpatient
        13X 14X
      • Skilled Nursing - Inpatient
        21X 22X
      • Skilled Nursing - Outpatient
        21X 24X
      • Home Health Clinic
        33X 34X
      • Special Facility
        71X 72X 73X 74X 75X 79X 81X 82X 83X 84X 89X
    2. Valid third digit codes:
      1. Admit through discharge claim
      2. Interim - First claim
      3. Interim - Continuing Claim
      4. Interim - Last Claim
      5. Late charges only claim
      6. Adjustment of prior claim (must submit on paper)
      7. Replacement of prior claim (must submit on paper)
  5. Federal Tax Number
    Optional. Enter your federal tax identification number
  6. Statement Covers Period
    Enter statement covers from and through date. Must be in MMDDYY format.
  7. Covered Days
    Enter number of covered days
  8. Non-Covered Days
    Enter number of non-covered days.
  9. Coinsurance Days
    Enter number of co-insurance days.
  10. Lifetime Reserve Days
    Enter lifetime reserve days.
  11. Blank
  12. Patient Name
    Enter patient's last name, first name and middle initial.
  13. Patient Address
    Enter patient's full mailing address including street number, city, state and zip code.
  14. Patient Birth Date
    Enter patient's date of birth. Must be in MMDDYY format.
  15. Patient Sex
    Enter patient's sex.
  16. Patient Marital Status
    Optional. Enter patient's marital status.
  17. Admission Date
    Enter date patient is admitted for this stay. Must be in MMDDYY format.
  18. Admission Hour
    Optional for all inpatient claims. Enter the admission hour code.
  19. Type of Admission
    Enter the type of admission code.
    Valid type of admission codes:
    • 1 - Emergency
    • 2 - Urgent
      3 - Elective
      4 - Newborn
      9 - Information not available
  20. Source of Admission
    Enter the source of admission code.
    1. Valid source of admission codes:
      • 1 - Normal delivery
      • 2 - Premature delivery
      • 3 - Sick baby
      • 4 - Extramural birth (and Newborns)
      • 9 - Information not available
    2. Admissions other than newborn
      • 1 - Physician referral
      • 2 - Clinic referral
      • 3 - HMO referral
      • 4 - Transfer from a hospital
      • 5 - Transfer from a skilled nursing facility
      • 6 - Transfer from another health care facility
      • 7 - Emergency Room
      • 8 - Court/Law enforcement
      • 9 - Information not available
  21. Discharge Hour
  22. Patient Status
    Required for outpatient claims if the patient status code is other than 01. Enter patient status code.
  23. Medical Health Record Number
    Optional.
  24. Condition Codes
    Optional (24-30)

  1. Condition Codes
    Optional (24-30)
  2. Blank
  3. Occurrence Codes and Dates
    Enter one occurrence code for each additional date.
    Enter an occurrence date for each occurrence code. Must be in MMDDYY format.
    (32-35)

  1. Occurrence Codes and Dates
    Enter one occurrence code for each additional date.
    Enter an occurrence date for each occurrence code. Must be in MMDDYY format.
    (32-35)
  2. Occurrence Span Codes and Dates
    Required if occurrence span from and thru dates are entered.
    Enter occurrence span code.
    From and Thru Dates
    Required if an occurrence span code is entered.
    Enter from and thru dates. Must be in MMDDYY format.
  3. blank
  4. Patient's Mailing Address Block
  5. Value Codes and Amounts (39-41)
    Enter value code.
    Amount is required when a value code is entered.
    If value code 45 is entered then amount needs to reflect an admission hour.

  1. Revenue Code
    See Section E for a complete listing of available revenue codes. An accommodation revenue code (100-219) is required for all inpatient TOB.
  2. Revenue Description
    Optional. A narrative description of the related revenue categories included on the claim. Abbreviations may be used.
  3. Procedure Code and Modifier
    A CPT or HCPCS code is required for outpatient services or supplies.
  4. Service Date
    Enter the date that the services were provided. Must be in MMDDYY format.
  5. Units of Service
    Enter the number of units rendered for each service. Units can be hours, days/sessions, tests/services or items. See page E-20.
  6. Total Charges
    Enter total charges pertaining to the related revenue code for the current billing period. Zeros are valid.
  7. Non-Covered Charges
    Optional. Enter non-covered charges.
  8. Blank
    Where red line breaks image
  9. Payer Identification
    Enter the payer name for all known third party payers for this patient.
  10. Provider Number
    Enter the number assigned to the provider by the payers listed in Form
  11. Release of Information Certification Indicator
    Optional.
  12. Assignment of Benefits Certification Indicator
    Optional.
  13. Prior Payments-Payers and Patient
    Required if billing for Preferred Choice Sixty-Five in the secondary payer position
    Enter the amount of the prior payments from other insurance.
  14. Estimated Amount Due
    Optional.
  15. Blank
  16. Blank
  17. Insured's Name
    Enter the insured's last name, first name and middle initial as it appears on the identification card.
  18. Patient's Relationship to Insured
    Enter patient's relationship to insured code
  19. Insured's Identification Number
    Enter insured's identification number as shown on identification card.
  20. Insured's Group Name
    Optional.
  21. Insurance Group Number
    Enter the insured's group number as shown on the identification card. For Prepaid Services Claims enter "PPS".
  22. Treatment Authorization Code
    Optional
  23. Employment Status Code
    Optional.
  24. Employer Name
    Optional.
  25. Employer Location
    Optional.
  26. Principal Diagnosis Code
    Enter the principle diagnosis code. Must be a valid ICD-9 or DSM III diagnosis code. Diagnosis codes must be carried to their highest degree of detail (4th or 5th digit).
  27. Other Diagnoses Codes (68-75)
    Enter other diagnoses codes corresponding to additional conditions.Must be a valid ICD-9 or DSM III diagnosis code. Diagnosis codes must be carried to their highest degree of detail.

  1. Admitting Diagnosis
    Must be a valid ICD-9 or DSM III diagnosis code.
  2. External Cause of Injury Code (E-Code)
    Must be a valid ICD-9 or DSM III diagnosis code.
  3. DRG Assignment
    Optional.
  4. Procedure Coding Method Used
    Optional.
  5. Principal Procedure Code and Date
    Enter the principal procedure code and date. Must be a valid ICD-9 procedure code. Date must be in MMDDYY format.
  6. Other Procedure Codes and Dates
    Enter other procedure codes and dates. Must be a valid ICD-9 procedure code. Date must be in MMDDYY format.
  7. Attending Physician ID and Name
    Enter the unique physician identification number (UPIN) and the name of the attending physician for inpatient bills or the physician that requested the outpatient services.
    Definition of attending physician: The name and UPIN of the licensed physician who would normally be expected to certify and recertify the medical necessity of the services rendered and/or who has primary responsibility for the patient's medical care and treatment.
    Inpatient - Enter the UPIN and name of the clinician who is primarily and largely responsible for the care of the patient from the beginning of the hospital episode.
    Outpatient - Enter the UPIN and name of the physician that requested surgery, therapy, diagnostic tests or other services.
  8. Other Physician ID and Name
    Optional
  9. Remarks
    1. If revenue code 255, 350, 351 or 359 are entered in Form Locator 42, remarks should specify if ionic or non-ionic contrast media was used.
    2. If revenue code 450, 456 or 459 are entered in Form Locator 42, remarks should clarify circumstances for emergency room visit, i.e. who, what, when, where, why, how and time of day. Use of E-Code and Occurrence codes are valid.
    3. If revenue code 942 is entered in Form Locator 42 for outpatient claims, remarks should provide description of service, training schedule and name of educational program.
    4. If CPT codes are used in place of HCPCS codes with any of the following revenue codes entered in Form Locator 44, remarks should specify the type of drug, implant, or device:
      • 254 - Drugs incident to other diagnostic service
      • 256 - Experimental drugs
      • 259 - Other pharmacy
      • 274 - Prosthetic device
      • 278 - Other implants
      • 279 - Other supplies/devices
      • 623 - Surgical dressings
      • 624 - Investigational device
      • 636 - Drugs requiring detailed coding
      • 637 - Self-administrable drugs
    5. If CPT codes are used in place of HCPCS codes with any of the following revenue codes entered in Form Locator 44, remarks should specify the type of equipment and for rental equipment, the period of rental:
      • 290 - General Classification
      • 291 - Rental
      • 292 - Purchase of new equipment
      • 293 - Purchase of used equipment
      • 294 - Supplies/drugs for DME effectiveness
      • 299 - Other equipment
    6. If occurrence codes 01-05 are entered in Form Locators 32-35 and/or diagnosis codes 800-959.9, E800-849, E880-E929, E969-E999 are entered in Form Locators 67-76 or E999 is entered in Form Locator 77, remarks should clarify accident information, i.e. who, what, when, where, why, how and time of day.
    7. For Regence HMO Oregon claims only: If a referral has been made to the hospital by the primary care provider (PCP), you may enter the full name of the PCP (first, middle initial, last name) and the date the referral was made. This information may be given in lieu of a call from the PCP to Regence HMO Oregon to process the claim.
  10. Signature and Date
    Provider Representative