Sec. 31.10.11.09. Essential Data Elements for Clean Claims by Hospitals

A. In General. To qualify as a clean claim, a claim submitted to a third-party payor by a hospital, or person entitled to reimbursement, shall conform to the applicable standard code set and include the following data elements:

(1) Hospital's, or person entitled to reimbursement's, name, address, and telephone number (HCFA Form UB-92, field 1);

(2) Patient's control number (HCFA Form UB-92, field 3);

(3) Type of bill code (HCFA Form UB-92, field 4);

(4) Hospital's, or person entitled to reimbursement's, federal tax ID number (HCFA Form UB-92, field 5);

(5) Beginning and ending date of claim period (HCFA Form UB-92, field 6);

(6) Patient's name (HCFA Form UB-92, field 12);

(7) Patient's address (HCFA Form UB-92, field 13);

(8) Patient's date of birth (HCFA Form UB-92, field 14);

(9) Patient's gender (HCFA Form UB-92, field 15);

(10) Patient's marital status (HCFA Form UB-92, field 16);

(11) Date of admission (HCFA Form UB-92, field 17);

(12) Admission hour (HCFA Form UB-92, field 18);

(13) Type of admission (for example, emergency, urgent, elective, newborn) (HCFA Form UB-92, field 19);

(14) Source of admission code (HCFA Form UB-92, field 20);

(15) Patient-status-at-discharge code (HCFA Form UB-92, field 22);

(16) Medical record number (HCFA Form UB-92, field 23);

(17) Responsible party name and address (HCFA Form UB-92, field 38);

(18) Value code and amounts (HCFA Form UB-92, fields 39-41);

(19) Applicable revenue code (HCFA Form UB-92, field 42) of:

(a) The Health Services Cost Review Commission, for hospitals located in the State, or

(b) The National or State Uniform Billing Data Elements Specifications, for hospitals not located in the State;

(20) Revenue description (HCFA Form UB-92, field 43);

(21) Service date (HCFA Form UB-92, field 45);

(22) Units of service (HCFA Form UB-92, field 46);

(23) Total charge (HCFA Form UB-92, field 47);

(24) Noncovered charges (HCFA Form UB-92, field 48);

(25) Name of the third-party payor (HCFA Form UB-92, field 50);

(26) Provider number (HCFA Form UB-92, field 51);

(27) Release of information (HCFA Form UB-92, field 52);

(28) Assignment of benefits (HCFA Form UB-92, field 53);

(29) Estimated amount due (HCFA Form UB-92, field 55);

(30) Subscriber's name (HCFA Form UB-92, field 58);

(31) Patient's relationship to the subscriber (HCFA Form UB-92, field 59);

(32) Patient's/subscriber's certificate number, health claim number, and ID number (HCFA Form UB-92, field 60);

(33) Treatment authorization code (HCFA Form UB-92, field 63);

(34) Principal diagnosis code (HCFA Form UB-92, field 67);

(35) Admitting diagnosis (HCFA Form UB-92, field 76);

(36) Attending physician ID (HCFA Form UB-92, field 82);

(37) Other physician ID (HCFA Form UB-92, field 83);

(38) Signature of the provider representative or notation that the signature is on file with the third-party payor (HCFA Form UB-92, field 85);

(39) Date the bill was submitted (HCFA Form UB-92, field 86); and

(40) Any other field or essential data element necessary to comply with the applicable standard code set.

B. Specific Circumstances. In addition to the data elements required by §A of this regulation, to qualify as a clean claim, a claim submitted to a third-party payor by a hospital, or person entitled to reimbursement, shall include the following data elements if circumstances exist that render the data elements applicable to the specific claim being filed:

(1) Covered days (HCFA Form UB-92, field 7) is applicable if Medicare is a primary or secondary payor;

(2) Noncovered days (HFCA Form UB-92, field 8) is applicable if Medicare is a primary or secondary payor;

(3) Coinsurance days (HFCA Form UB-92, field 9) is applicable if Medicare is a primary or secondary payor;

(4) Lifetime reserve days (HCFA Form UB-92, field 10) is applicable if Medicare is a primary or secondary payor and the patient was an inpatient;

(5) The discharge hour (HCFA Form UB-92, field 21) is applicable if the patient was an inpatient or was admitted for outpatient observation;

(6) The condition codes (HCFA Form UB-92, fields 24-30) are applicable if the HCFA Form UB-92 manual contains a condition code appropriate to the patient's condition;

(7) The occurrence codes and dates (HCFA Form UB-92, fields 32-35) are applicable if the HCFA Form UB-92 manual contains an occurrence code appropriate to the patient's condition;

(8) The occurrence span code and from and through dates (HCFA Form UB-92 field 36) are applicable if the HCFA Form UB-92 manual contains an occurrence span code appropriate to the patient's condition;

(9) HCPCS/Rates (HCFA Form UB-92, field 44) are applicable if there is a primary or secondary payor;

(10) A code pursuant to a global contract (HCFA Form UB-92, field 44) is applicable if the claim is between parties to a global contract;

(11) Prior payments (HCFA Form UB-92, field 54) are applicable if payments have been made to the hospital by the patient or another payor;

(12) The employment status code (HCFA Form UB-92, field 64) is applicable if there are payors of higher priority than the third-party payor, including workers' compensation;

(13) The employer name (HCFA Form UB-92, field 65) is applicable if there are payors of higher priority than the third-party payor, including workers' compensation;

(14) The employer location (HCFA Form UB-92, field 66) is applicable if there is workers' compensation involvement;

(15) Diagnoses codes other than the principal diagnosis code (HCFA Form UB-92, field 68-75) are applicable if there are diagnoses other than the principal diagnosis;

(16) Diagnoses codes describing the patient's signs, or presenting symptoms, or both (HCFA Form UB 92, field 76) are applicable for services provided in a hospital emergency department;

(17) The procedure coding methods used (HCFA Form UB-92, field 79) are applicable if the HCFA Form UB-92 manual indicates a procedural coding method appropriate to the patient's condition;

(18) The principal procedure code (HCFA Form UB-92, field 80) is applicable if the patient has undergone an inpatient or outpatient surgical procedure; and

(19) Other procedure codes (HCFA Form UB-92, field 81) are applicable as an extension of §B(17) of this regulation if additional surgical procedures were performed.

C. A third-party payor may not use or require a hospital to use any field for purposes that are inconsistent with these data elements or in addition to the applicable standard code set.

D. A third-party payor may accept the HCFA Form UB-92 that includes data elements in addition to those set forth in §§A and B of this regulation.