Provider s name, address and telephone number Clean Claim Edits UB04 1 Yes Reject Reject if blank or if address is not a physical address (PO BOX, Lock BOX, etc is not valid). 9 Digit billing provider zip code is required. Reject Reason physician/provider Billing name and physical address and/or or Service Billing Provider 9 digit Zip Code Pay-to Name and Address 2 No Pass Patient control number 3 Yes Reject Reject if blank Patient Control Number Type of bill code 4 Yes Reject Reject if blank or Bill Type Invalid Bill Type Provider s federal tax ID number 5 Yes Reject Reject if blank or Provider Tax ID Number (needs to be Invalid Provider Tax ID Number 9 digits) Beginning and ending date of claim period 6 Yes Reject Reject if blank Beginning/End Dates of Service Not used 7 N/A Pass Patient s name 8 Yes Reject Reject if blank Patient's Name Patient s address 9 Yes Reject Reject if blank Patient Address Patient s date of birth 10 Yes Reject Reject if blank Patient DOB Patient's gender 11 Yes Reject Reject if blank Patient Gender Date of admission 12 Conditional Pass/Reject Required for Types 18X, 21X, 22X, 32X, 33X, 41X, 81X, 82X where X is any number Reject if date Date of Admission Invalid Date of Admission 1 of 5
Admission hour 13 Conditional Pass/Reject Required for Types 18X, 21X, 22X, 32X, 33X, 41X, 81X, 82X where X is any number Type of admission 14 Conditional Pass/Reject Required for Types 18X, 21X, 41X number Reject if blank or Reject Reason Admission Hour Type of Admission Invalid Type of Admission Source of admission code 15 No Pass/Reject Not required, but if Discharge hour 16 No Pass Patient-status-at-discharge code 17 Conditional Pass/Reject Required for Types of Bill 11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 33X, 34X, 41X, 71X, 73X, 74X, 75X, 76X, 81X, 82X, 85X number Reject if blank or Invalid Source of Admission Patient Status Discharge Code Invalid Patient Status Discharge Code 2 of 5
Condition codes 18-28 No Pass/Reject Not required, but if Accident State 29 Not Used Pass Not used 30 N/A Pass Occurrence codes and dates 31-34 No Pass/Reject Not required, but if Occurrence span code 35-36 No Pass/Reject Not required, but if Not used 37 N/A Pass Responsible Party 38 No Pass Value code and amounts 39-41 No Pass/Reject Not required, but if Revenue code 42 Yes Reject Reject if blank or Revenue/service description 43 No Pass HCPCS/Rates 44 Conditional Pass/Reject HCPCS Not required, but if one is provided, reject if Rates Required for all inpatient claims where Revenue Code (field 342) = 100-219 Reject Reason Invalid Condition Codes Invalid Occurrence Codes and Dates Invalid Occurrence Span Codes Invalid Value Codes and Amounts Revenue Code Invalid Revenue Code Invalid HCPCS Rate Invalid Rate 3 of 5
Reject Reason Service date 45 Yes Reject Reject if blank or Service Date Invalid Service and Date Date must be less than current date (No future dates) Units of service 46 Yes Reject Reject if blank Units of Service Total charge 47 Yes Reject Reject if blank Total Charges Non-covered charges 48 No Pass Not used 49 N/A Pass Payer Name 50 No Pass Health Plan ID 51 No Pass Release of Info Certification 52 Yes Reject Reject if blank Release of Information Certification Assignment of Benefit Certification 53 No Pass Prior payments 54 No Pass Estimated Amount Due 55 No Pass NPI number 56 Yes Reject Reject if blank or NPI (check sum logic) Other Provider ID 57 No Pass Insured's Name 58 No Pass Patient Relationship 59 No Pass Insured's Unique ID 60 No Pass Group Name 61 No Pass Group Insurance Number 62 No Pass Treatment Authorization Codes 63 No Pass Document Control Number 64 No Pass Employer name 65 No Pass NPI Number Invalid NPI Number 4 of 5
Reject Reason Diagnosis and Procedure Code Qualifier 66 Yes Reject Reject if blank Diagnosis or Procedure Code Qualifier Diagnosis Codes 67 Conditional Pass/Reject Required for Types Diagnosis Codes Invalid Diagnosis Codes 13X, 14X, 21X number, reject if Not used 68 N/A Pass Admitting diagnosis 69 Conditional Pass/Reject Required for Types 21X, and 22X number, reject if Patient Reason Diagnosis 70 No Pass PPS Code (DRG) 71 No Pass/Reject Not required, but if ECI Code 72 No Pass Not used 73 N/A Pass Procedure Codes 74 No Pass/Reject Not required, but if Not used 75 N/A Pass Attending physician ID 76 No Pass Operating physician ID 77 No Pass Other Provider ID 78-79 No Pass Remarks 80 No Pass 5 of 5