UB-04 Billing Instructions
Provider Type
- Physicians
- Participating Physician Groups (PPG)
(does not apply to HSP)
- Hospitals
- Ancillary
All claims from participating providers that are Health Net's responsibility must be submitted to Health Net Medi-Cal claims within 180 days from the last day of the month of the date services were rendered. EPO, HMO, HSP, Medicare Advantage, and PPO participating providers must be submitted claims to Health Net within 120 days from the date services were rendered, unless a different time frame is stated in the providers' contract. Health Net accepts claims submitted on the standard CMS-1500 and UB-04 form and computer generated claims using these formats.
Field number |
Field description |
Instruction or comments |
Required, conditional or not required |
|
|---|---|---|---|---|
1 |
Unlabeled field |
Line 1: Enter the complete provider name. **ALERT: Providers submitting paper claims should left-align data in this field. |
Required |
|
2 |
Unlabeled field |
Enter the pay-to name and address |
Not required |
|
3a |
Patient control no |
Enter the facility patient account/control number |
Not required |
|
3b |
Medical record number |
Enter the facility patient medical or health record number |
Required |
|
4 |
Type of bill |
Enter the appropriate type of bill (TOB) code as specified by the NUBC UB-04 Uniform Billing Manual minus the leading "0" (zero). A leading "0" is not needed. Digits should be reflected as follows: 1st Digit - Indicating the type of facility. |
Required |
|
5 |
Fed Tax No |
Enter the nine-digit number assigned by the federal government for tax reporting purposes |
Required |
|
6 |
Statement covers period from/through |
Enter begin and end, or admission and discharge dates, for the services billed. Inpatient and outpatient observation stays must be billed using the admission date and discharge date. Outpatient therapy, chemotherapy, laboratory, pathology, radiology, and dialysis may be billed using a date span. All other outpatient services must be billed using the actual date of service (MMDDYY). |
Required |
|
7 |
Unlabeled field |
Not used. |
Not required |
|
8a |
Patient name |
8a - Enter the first nine digits of the identification number on the member's ID card. |
Not required |
|
8b |
Enter the patient's last name, first name, and middle initial as it appears on the ID card. Use a comma or space to separate the last and first names. Titles: (Mr., Mrs., etc.) should not be reported in this field. Prefix: No space should be left after the prefix of a name (e.g., McKendrick. H). Hyphenated names: Both names should be capitalized and separated by a hyphen (no space). Suffix: a space should separate a last name and suffix. Enter the patient's complete mailing address. |
Required |
||
9 |
Patient address |
Enter the patient's complete mailing address. Line a: Street address |
Required - Except line 9e county code |
|
10 |
Birthdate |
Enter the patient's date of birth (MMDDYYYY) |
Required - Ensure DOB of patient is entered and not the insured) |
|
11 |
Sex |
Enter the patient's sex. Only M or F is accepted |
Required |
|
12 |
Admission date |
Enter the date of admission for inpatient claims and date of service for outpatient claims (MMDDYY) |
Required for Inpatient claims. Leave blank for Outpatient claims. Exceptions: Type of bill codes 012x, 022x, 032x, 034x, 081x, and 082x require boxes 12–13 to be populated. |
|
13 |
Admission hour |
Enter the time using two-digit military time (00-23) for the time of inpatient admission or time of treatment for outpatient services.
|
Required for Inpatient claims. Leave blank for Outpatient claims. Exceptions: Type of bill codes 012x, 022x, 032x, 034x, 081x, and 082x require boxes 12–13 to be populated. |
|
14 |
Admission type |
Require for inpatient and outpatient admissions. Enter the one-digit code indicating the type of the admission using the appropriate following codes:
|
Required |
|
15 |
Admission source |
Required for inpatient and outpatient admissions. Enter the one-digit code indicating the source of the admission or outpatient service using one of the following codes. For type of admission 1,2,3, or 5:
For type of admission 4 (newborn):
|
Required |
|
16 |
Discharge hour |
Enter the time using two-digit military times (00-23) for the time of the inpatient or outpatient discharge.
|
Conditional - Enter the time using two-digit military times (00-23) for the time of the inpatient or outpatient discharge |
|
17 |
Patient status |
REQUIRED for inpatient and outpatient claims. Enter the two-digit disposition of the patient as of the "through" date for the billing period listed in field 6 using one of the following codes:
|
Required |
|
18-28 |
Condition codes |
REQUIRED when applicable. Condition codes are used to identify conditions relating to the bill that may affect payer processing. Each field (18-24) allows entry of a two-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual |
Conditional REQUIRED when condition codes are used to identify conditions relating to the bill that may affect payer processing |
|
29 |
Accident state |
N/A |
Not required |
|
30 |
Unlabeled Field |
N/A |
Not required |
|
31-34 a-b |
Occurrence code and occurrence date |
Occurrence code: REQUIRED when applicable. Occurrence Codes are used to identify events relating to the bill that may affect payer processing. Each field (31-34a) allows for entry of a two-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual. Occurrence date: REQUIRED when applicable or when a corresponding occurrence code is present on the same line (31a-34a). Enter the date for the associated occurrence code in MMDDYY format |
Conditional REQUIRED when occurrence codes are used to identify events relating to the bill that may affect payer processing |
|
35-36 a-b |
Occurrence |
Occurrence span code: REQUIRED when applicable. Occurrence codes are used to identify events relating to the bill that may affect payer processing. Each field (35-36a) allows for entry of a two-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual. Occurrence span date: REQUIRED when applicable or when a corresponding occurrence span code is present on the same line (35a-36a). Enter the date for the associated occurrence code in MMDDYY format. |
Conditional REQUIRED when occurrence codes are used to identify events relating to the bill that may affect payer processing |
|
37 |
Unlabeled field |
REQUIRED for re-submissions or adjustments. Enter the DCN (document control number) of the original claim |
Conditional REQUIRED for resubmissions or adjustments. Enter the DCN (document control number) of the original claim |
|
38 |
Responsible party name and address |
N/A |
Not required |
|
39-41 a-d |
Value codes and amounts |
Code: REQUIRED when applicable. Value codes are used to identify events relating to the bill that may affect payer processing. Each field (39-41) allows for entry of a two-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). Up to 12 codes can be entered. All "a" fields must be completed before using "b" fields, all "b" fields before using "c" fields, and all "c" fields before using "d" fields. For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual. Amount: REQUIRED when applicable or when a value code is entered. Enter the dollar amount for the associated value code. Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e., 199,999.99). Do not enter a dollar sign ($) or a decimal. A decimal is implied. If the dollar amount is a whole number (i.e., 10.00), enter 00 in the area to the right of the vertical line |
Conditional REQUIRED when value codes are used to identify events relating to the bill that may affect payer processing |
|
42 |
REV CD |
Enter the appropriate revenue codes itemizing accommodations, services, and items furnished to the patient. Refer to the NUBC UB-04 Uniform Billing Manual for a complete listing of revenue codes and instructions. Enter accommodation revenue codes first followed by ancillary revenue codes. Enter codes in ascending numerical value |
Required |
|
42 |
Rev CD |
Enter 0001 for total charges. |
Required |
|
43 |
Description |
Enter a brief description that corresponds to the revenue code entered in the service line of field 42 |
Required |
|
43 |
PAGE ___ OF ___ |
Enter the number of pages. Indicate the page sequence in the "PAGE" field and the total number of pages in the "OF" field. If only one claim form is submitted, enter a "1" in both fields (i.e., PAGE "1" OF "1"). (Limited to 4 pages per claim) |
Conditional - Enter the number of pages. (Limited to 4 pages per claim) |
|
44 lines 1-22 |
HCPCS/Rates |
REQUIRED for outpatient claims when an appropriate CPT/HCPCS code exists for the service line revenue code billed. The field allows up to nine characters. Only one CPT/HCPCS and up to two modifiers are accepted. When entering a CPT/HCPCS with a modifier(s), do not use spaces, commas, dashes, or the like between the CPT/HCPCS and modifier(s). Refer to the NUBC UB-04 Uniform Billing Manual for a complete listing of revenue codes and instructions. Please refer to your current provider contract |
Conditional REQUIRED for outpatient claims when an appropriate CPT/HCPCS code exists for the service line revenue code billed |
|
45 |
Service date |
REQUIRED on all outpatient claims. Enter the date of service for each service line billed (MMDDYY). Multiple dates of service may not be combined for outpatient claims |
Conditional REQUIRED on all outpatient claims. Enter the date of service for each service line billed (MMDDYY). Multiple dates of service may not be combined for outpatient claims |
|
45 |
Creation date |
Enter the date the bill was created or prepared for submission on all pages submitted (MMDDYY). |
Required |
|
46 lines 1-22 |
Service units |
Enter the number of units, days, or visits for the service. A value of at least "1" must be entered. For inpatient room charges, enter the number of days for each accommodation listed |
Required |
|
47 |
Total charges |
Enter the total charge for each service line |
Required |
|
47 |
Totals |
Enter the total charges for all service lines |
Required |
|
48 |
Non-covered charges |
Enter the non-covered charges included in field 47 for the revenue code listed in field 42 of the service line. Do not list negative amounts |
Conditional - Enter the noncovered charges included in field 47 for the revenue code listed in field 42 of the service line. Do not list negative amounts |
|
48 |
Totals |
Enter the total non-covered charges for all service lines |
Conditional - Enter the total noncovered charges for all service lines |
|
49 |
Unlabeled field |
Not used |
Not required |
|
50 A-C |
Payer |
Enter the name of each payer from which reimbursement is being sought in the order of the payer liability. Line A refers to the primary payer; B, secondary; and C, tertiary |
Required |
|
51 A-C |
Health plan identification number |
N/A |
Not required |
|
52 A-C |
REL information |
REQUIRED for each line (A, B, C) completed in field 50. Release of Information Certification Indicator. Enter 'Y' (yes) or 'N' (no). Providers are expected to have necessary release information on file. It is expected that all released invoices contain 'Y' |
Required |
|
53 |
ASG. BEN. |
Enter 'Y' (yes) or 'N' (no) to indicate a signed form is on file authorizing payment by the payer directly to the provider for services |
Required |
|
54 |
Prior payments |
Enter the amount received from the primary payer on the appropriate line |
Conditional - Enter the amount received from the primary payer on the appropriate line when Health Net is listed as secondary or tertiary |
|
55 |
EST amount due |
N/A |
Not required |
|
56 |
National Provider Identifier or provider ID |
REQUIRED: Enter providers 10-character NPI ID |
Required |
|
57 |
Other provider ID |
Enter the numeric provider identification number. Enter the TPI number (non-NPI number) of the billing provider |
Required |
|
58 |
Insured's name |
For each line (A, B, C) completed in field 50, enter the name of the person who carries the insurance for the patient. In most cases this will be the patient's name. Enter the name as last name, first name, middle initial |
Required |
|
59 |
Patient relationship |
N/A |
Not required |
|
60 |
Insured unique ID |
REQUIRED: Enter the patient's insurance ID exactly as it appears on the patient's ID card. Enter the insurance ID in the order of liability listed in field 50 |
Required |
|
61 |
Group name |
N/A |
Not required |
|
62 |
Insurance group no. |
N/A |
Not required |
|
63 |
Treatment authorization code |
Enter the prior authorization or referral when services require precertification |
Conditional - Enter the prior authorization or referral when services require precertification |
|
64 |
Document control number |
Enter the 12-character original claim number of the paid/denied claim when submitting a replacement or void on the corresponding A, B, C line Applies to claim submitted with a type of bill (field 4), frequency of "7" (replacement of prior claim) or type of bill, frequency of "8" (void/cancel of prior claim). *Please refer to the reconsider/corrected claims section |
Conditional - Enter the 12-character original claim number of the paid/denied claim when submitting a replacement or void on the corresponding A, B, C line reflecting Payer from field 50 |
|
65 |
Employer name |
N/A |
Not required |
|
66 |
DX version qualifier |
N/A |
Required |
|
67 |
Principal diagnosis code |
Enter the principal/primary diagnosis or condition using the appropriate release/update of ICD-10-CM Volume 1 & 3 for the date of service |
Required |
|
67 A-Q |
Other diagnosis code |
Enter additional diagnosis or conditions that coexist at the time of admission or that develop subsequent to the admission and have an effect on the treatment or care received using the appropriate release/update of ICD-10CM Volume 1 & 3 for the date of service. Diagnosis codes submitted must be valid ICD-10 Codes for the date of service and carried out to its highest level of specificity - 4th or 5th digit. "E" and most "V" codes are NOT acceptable as a primary diagnosis. Note: Claims with incomplete or invalid diagnosis codes will be denied |
Conditional - Enter additional diagnosis or conditions that coexist at the time of admission |
|
68 |
Present on admission indicator |
Required |
||
69 |
Admitting diagnosis code |
Enter the diagnosis or condition provided at the time of admission as stated by the physician using the appropriate release/update of ICD-10-CM Volume 1 & 3 for the date of service. Diagnosis codes submitted must be valid ICD-10 codes for the date of service and carried out to its highest level of specificity - 4th or 5th digit. "E" codes and most "V" are NOT acceptable as a primary diagnosis. Note: Claims with missing or invalid diagnosis codes will be denied |
Required |
|
70 |
Patient reason code |
Enter the ICD-10-CM code that reflects the patient's reason for visit at the time of outpatient registration. Field 70a requires entry; fields 70b-70c are conditional. Diagnosis codes submitted must be valid ICD-10 codes for the date of service and carried out to its highest digit - 4th or 5th. "E" codes and most "V" codes are NOT acceptable as a primary diagnosis. NOTE: Claims with missing or invalid diagnosis codes will be denied |
Required |
|
71 |
PPS/DRG code |
N/A |
Not required |
|
72 a, b, c |
External cause code |
N/A |
Not required |
|
73 |
Unlabeled field |
N/A |
Not required |
|
74 |
Principal procedure code/date |
CODE: Enter the ICD-10 procedure code that identifies the principal/primary procedure performed. Do not enter the decimal between the 2nd or 3rd digits of code; it is implied. DATE: Enter the date the principal procedure was performed (MMDDYY). |
Conditional - Enter the ICD-10 procedure code that identifies the principal/primary procedure performed. Do not enter the decimal between the 2nd or 3rd digits of code; it is implied. DATE: Enter the date the principal procedure was performed (MMDDYY) |
|
74 a-e |
Other procedure code date |
REQUIRED on inpatient claims when a procedure is performed during the date span of the bill. CODE: Enter the ICD-10 procedure code(s) that identify significant procedure(s) performed other than the principal/primary procedure. Up to five ICD-10 procedure codes may be entered. Do not enter the decimal; it is implied. DATE: Enter the date the principal procedure was performed (MMDDYY). |
Conditional REQUIRED on inpatient claims when a procedure is performed during the date span of the bill |
|
75 |
Unlabeled field |
N/A |
Not required |
|
76 |
Attending physician |
Enter the NPI and name of the physician in charge of the patient care.
|
Required |
|
77 |
Operating physician |
REQUIRED when a surgical procedure is performed. Enter the NPI and name of the physician in charge of the patient care.
|
Conditional REQUIRED when a surgical procedure is performed. Enter the NPI and name of the physician in charge of the patient care |
|
78 & 79 |
Other physician |
Enter the provider type qualifier, NPI and name of the physician in charge of the patient care.
|
Conditional |
|
80 |
Remarks |
N/A |
Not required |
|
81 |
CC |
A: Taxonomy of billing provider. Use B3 qualifier. |
Required |
|
82 |
Attending Physician |
Enter name or seven-digit provider number of ordering physician |
Required |
|