Texas Register, Volume 32, Number 3, Pages 215-274, January 19, 2007 Page: 235
215-274 p. ; 28 cmView a full description of this periodical.
Extracted Text
The following text was automatically extracted from the image on this page using optical character recognition software:
(2)(P) [(1)(P)] of this subsection and as required by subsection (d) of
this section;
(JJ) signature of physician or provider or notation that
the signature is on file with the HMO or preferred provider carrier
(CMS-1500 (12/90) [CMS -1500], field 31) is required;
(KK) name and address of facility where services ren-
dered (if other than home or office) (CMS-1500 (12/90) [GCMS 1500],
field 32) is required; and
(LL) physician's or provider's billing name, address,
and telephone number is required, and the provider number (CMS-
1500 (12/90) [MS 15t00], field 33) is required if the HMO or pre-
ferred provider carrier required provider carrier requiredprovider numbers and gave notice of
that requirement to physicians and providers prior to June 17, 2003.
(3) Required form and data elements for institutional
providers for claims filed or re-filed on or after May 23, 2007. The
UB-04 CMS-1450 and the data elements described in this paragraph
are required as indicated and must be completed in accordance with
the special instructions applicable to the data elements for clean
claims filed by institutional providers. Further, upon notification that
an HMO or preferred provider carrier is prepared to accept claims
filed or re-filed on form UB-04 CMS-1450, an institutional provider
may submit claims on UB-04 CMS-1450, subject to the required data
elements set forth in this paragraph, at any time between March 1,
2007 and May 22, 2007.
(A) provider's name, address, and telephone number
(UB-04, field 1) is required;
(B) patient control number (UB-04, field 3a) is re-
quired;
(C) type of bill code (UB-04, field 4) is required and
shall include a "7" in the fourth position if the claim is a corrected claim;
(D) provider's federal tax ID number (UB-04, field 5)
is required;
(E) statement period (beginning and ending date of
claim period) (UB-04, field 6) is required;
(F) patient's name (UB-04, field 8a) is required;
(G) patient's address (UB-04, field 9a - 9e) is required;
(H) patient's date of birth (UB-04, field 10) is required;
(I) patient's gender (UB-04, field 11) is required;
(J) date of admission (UB-04, field 12) is required for
admissions, observation stays, and emergency room care;
(K) admission hour (UB-04, field 13) is required for ad-
missions, observation stays, and emergency room care;
(L) type of admission (e.g., emergency, urgent, elective,
newborn) (UB-04, field 14) is required for admissions;
(M) source of admission code (UB-04, field 15) is re-
quired;
(N) discharge hour (UB-04, field 16) is required for ad-
missions, outpatient surgeries, or observation stays;
(0) patient-status-at-discharge code (UB-04, field 17)
is required for admissions, observation stays, and emergency room
care;
(P) condition codes (UB-04, fields 18 - 28) are required
if the CMS UB-04 manual contains a condition code appropriate to the
patient's condition;(Q) occurrence codes and dates (UB-04, fields 31 - 34)
are required if the CMS UB-04 manual contains an occurrence code
appropriate to the patient's condition;
(R) occurrence span codes and from and through dates
(UB-04, fields 35 and 36) are required if the CMS UB-04 manual con-
tains an occurrence span code appropriate to the patient's condition;
(S) value code and amounts (UB-04, fields 39 - 41) are
required for inpatient admissions. If no value codes are applicable to
the inpatient admission, the provider may enter value code 01;
(T) revenue code (UB-04, field 42) is required;
(U) revenue description (UB-04, field 43) is required;
(V) HCPCS/Rates (UB-04, field 44) are required if
Medicare is a primary or secondary payor;
(W) service date (UB-04, field 45) is required if the
claim is for outpatient services;uired;
(X) date bill submitted (UB-04, field 45, line 23) is re-
(Y) units of service (UB-04, field 46) are required;
(Z) total charge (UB-04, field 47) is required;
(AA) HMO or preferred provider carrier name (UB-04,field 50) is required;
(BB) prior payments-payor (UB-04, field 54) are re-
quired if payments have been made to the physician or provider by a
primary plan as required by subsection (d) of this section;
(CC) for claims filed or re-filed on or after May 23,
2007, the NPI number of the billing provider (UB-04, field 56) is re-
quired if the billing provider is eligible for an NPI number;
(DD) other provider number (UB-04, field 57) is
required if the HMO or preferred provider carrier, prior to June 17,
2003, required provider numbers and gave notice of that requirement
to physicians and providers;
(EE) subscriber's name (UB-04, field 58) is required if
shown on the patient's ID card;
(FF) patient's relationship to subscriber (UB-04, field
59) is required;
(GG) patient's/subscriber's certificate number, health
claim number, ID number (UB-04, field 60) is required if shown on the
patient's ID card;
(HH) insurance group number (UB-04, field 62) is re-
quired if a group number is shown on the patient's ID card;
(II) verification number (UB-04, field 63) is required if
services have been verified pursuant to 19.1724 of this title. If no
verification has been provided, treatment authorization codes (UB-04,
field 63) are required when authorization is required and granted;
(JJ) principal diagnosis code (UB-04, field 67) is re-
quired;
(KK) diagnoses codes other than principal diagnosis
code (UB-04, fields 67A - 67Q) are required if there are diagnoses other
than the principal diagnosis;
(LL) admitting diagnosis code (UB-04, field 69) is re-
quired;PROPOSED RULES January 19, 2007 32 TexReg 235
Upcoming Pages
Here’s what’s next.
Search Inside
This issue can be searched. Note: Results may vary based on the legibility of text within the document.
Tools / Downloads
Get a copy of this page or view the extracted text.
Citing and Sharing
Basic information for referencing this web page. We also provide extended guidance on usage rights, references, copying or embedding.
Reference the current page of this Periodical.
Texas. Secretary of State. Texas Register, Volume 32, Number 3, Pages 215-274, January 19, 2007, periodical, January 19, 2007; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth97380/m1/20/: accessed April 24, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.