Skip to main content
  • Medicaid Provider Alert: Provider revalidation has begun and those not completing the process risk disenrollment.  Check your account now to learn when your revalidation is due. More information here.
Elizabeth M. Whitehorn, Director

Provider Notice issued 12/21/06

UB-04 Fields Required for HFS Processing

To:​

Participating Hospitals – Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers; Hospice Agencies; Renal Dialysis Facilities; and Ambulatory Surgical Treatment Centers (ASTCs)​

Date:​ December 21, 2006​
Re:​ UB-04 Fields Required for HFS Processing​

This provider notice identifies specific information that is needed by the Illinois Department of Healthcare and Family Services for adjudication of claims billed on the UB-04 Claim Form. The information contained in this notice is intended to be used in conjunction with the UB-04 Data Specifications Manual, as the Manual identifies other required data fields on the UB-04. To become a UB-04 Subscriber, refer to the following Web site: http://www.nubc.org/become.html

 

The department will not meet the May 23, 2007, deadline for accepting the UB-04 claim format for processing. Institutional providers must continue to submit paper claims on the UB-92 Claim Form until further notification by the department. Providers must also continue to report the HFS provider number, not the National Provider Identifier (NPI), on the UB-92. The NPI will not be utilized until the implementation of the UB-04.

 

The table included with this notice identifies the fields of the UB-04 that are required for HFS processing. Any questions should be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

 

Anne Marie Murphy, Ph.D.

Administrator

Division of Medical Programs

 

UB-04 Fields Required for HFS Processing

 

FORM LOCATOR

DESCRIPTION

FL 02

Pay-To Name (Line 1)

Report your one-digit payee code preceding the pay-to name.

Pay-To Address (Lines 2 and 3)

Situational – Required when the address for payment is different than that of the Billing Provider in FL 01.

FL 08

Patient Name (Required)

Patient Name ID (Situational)

FL 09

Patient Address (Required)

For HFS, the patient is always the subscriber, as it relates to FL 58 (Insured’s Name) and FL 60 (Insured’s Unique Identifier). This information corresponds to the Illinois Medicaid Payer Lines A, B, or C.

FL 39-FL 41

Value Codes.

UB-92 FL 07, 08, 09, and 10 have been eliminated on the UB-04 and substituted with new Value Codes.

Value Code 80 – Covered Days

Value Code 81 – Non-Covered Days

Value Code 82 – Coinsurance Days

Value Code 83 – Lifetime Reserve Days

Do not use these Value Codes when billing an 837I. Use Claim Quantity in Loop 2300, QTY01.

FL 51

Health Plan Identification Number.

HFS will require that providers report our legacy 3-digit TPL codes and 2-digit TPL status codes in this field until the HIPAA National Plan Identifier is mandated. The format will continue to be the 3-digit TPL code, 1 space, then the 2-digit status code (6 bytes total). There can be up to 3 payer lines, which correspond with FL 50 (Payer Name).

FL 56

National Provider Identifier – Billing Provider

FL 64

Document Control Number (DCN)

HFS will utilize this field for the original DCN that is tied to the Void and Rebill process, at the time HFS implements the Void/Rebill process. This field will only be populated when submitting a type of Bill Frequency of “7” (Replacement of Prior Claim) or Type of Bill Frequency of “8” (Void/Cancel of Prior Claim).

FL 80

Remarks

HFS will utilize this field to assign their unique Document Control Number (DCN). Providers should not report any information in this field.

FL 81

Code-Code Field (situational).

To report additional codes related to a Form Locator (overflow). HFS Requirement (Needed for Adjudication) Qualifier “B3” – Healthcare Provider Taxonomy code