Texas Register, Volume 38, Number 46, Pages 8023-8312, November 15, 2013 Page: 8,120
8023-8312 p. ; 28 cm.View a full description of this periodical.
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(00) attending physician NPI number (UB-04, field
76) is required [en or after May 2~ 2008 ] if the attending physician is
eligible for an NPI number; and (PP) attending physician ID (UB-04,
field 76, qualifier portion) is required.
(PP) attending physician ID (UB-04, field 76, qualifier
portion) is required.
(4) Req uired form and data elements for institutional
providers for claims filed or re-filed before July 48 2007. The
TUB-92 Cq S-450 and the data elements described in this paragraph
are required for claims filed or re-filed by institutional providers
before July 4- 2007. The UB-92 CMS-!450 must be completed in
accordance with the special instructions applicable to the data element
as described in this paragraph for clean claims filed by institutional
providers, Howeer- upon notification that an HM, or preferred
provider earlier xi accept claims filed or re-filed on form UB-04
CMS-4 50, an institutional provider may submit laims on form
UB-04 CMS-T4 prior to the subsection (b)) mandatory use dateS
subie"t to the subsectiont ()() { required data elements.4
{(A) providers name, address and telephone number
(UB-9 field ) is required;]
t(B) patient control number (UB-92 field 3) is re-
ttquired
t(( type of bill code (UB-92, field 4) is required and
shall include a 7" in the third position if the claim is a corrected claim;]
D) provider's federal tax ID number (UB-92 field 5)
is required;
.) statement period (beginning and ending date of
elaim period) (UB-9 field 6) is required;
(F) covered days (UB-92, field 7-)is required if Medi-
care is a primary or secondary pay.or
1(G) noneevered days (UB-92 field } is required if
Medicare is a primary or secondary payor;
) coinsurance days (UB92 field 9) is required if
Medicare is a primary or secondary payor;
f(T) lifetime reserve days (UB-92, field 40) is required
if Medicare is a primary or secondary payer and the patient was an
9) patients name (UB-9 field 4-2) is required;]
) patient's address (UB-9 field 4-3) is required;]
) patient's date ofbirth (UB-92 field -4)is required;]
Y patient's gender UB-9T field 4-5) is required
{(N) patient's marital status s (UB-9 field 16) is re-
{(0} date of admission n T(B-9 field 4-7) is required for
admissions observation st . and emergency room care
{(P) admission hour (UB-9 fi ke 8) is required for
admissions observation stays and emergency room eare;]
1(Q) type of admission (e~g emergency, urgent elee-
tive newborn) (UB-9 field i9) is required for admissions;]
t() sorc ef admision oede (UB-924 fiekd 20) is re-
t(S) disdharge hour (UB-92 fied 2) is required for ad-
msOnsl outpatient surgeries or observation stays,T) atint-status .at discharge code (UB-92 field 22)
is required for admissions observation stas and emergency room
-3eare
t(e) condition codes (UB-92 fields 24 - 3) are
required if the CMS UB-92 manual contains a condition ede appre-
priate to the patient's conditinA
c(V ecurrence eedes and dates (UB-92, fields 32- 35)
are required if the CMS UB-92 manual contains an occurrene eede
appropriate to the patient's condition;
-W) occurrence span ode, from and through dates
(UB-92, field ,34 are required if the CMS UB-92 manual contains an
occurrene span e appropriate t the patient condition;
(X) value ede and amounts (UB-92 fields 39-441) are
rtuird for inpattient admissions. f value des are applicable to
the inpatient admissf the provider may enter value ede 04-
(f ) revenue code (UB-92 field 42) is required;]
(2z) ea dese;ript--ion (UB-92 field 43) is required;]
r(AA) HCPGS/Rates (UB-92 field 44) are required if
Medicare is a primary or seondary payor
.) 4erviee date (UB-9 field 45) is required if the
claim is for outpatient services;
G) units of service (UB-9 field 46) are required;]
-1 ) total charge (-B-9 field 47) is required;]
1(rE) HMO or preferred provider earier name (UB-92
field 50) is required;]
{(FF) provider number (UB-92 field 51) is required if
the ~ eo r preferred provider a i prior to June 47 2003 required
provider numbers and gave notice of that requirement to physiciansT and
G) prior payments-payer and patient (UB-92 field
54) are required if payments have been made to the physician or
provider by the patient or another payer or sutbscriber- on behalf f the
aient or subsribe or by a primary plan as required by subsetion
(4) of thissetion
t(8 ) subscribers' name (UB-92 field 58) is required
if shown on the patients nt eard
() patients relationship to subscriber (UB-9T field
59) is required;]
9J ; patient's/subscriber's ee tific-ate number,- health
elaim number ) number (UB-9 field 60) is required if shown on
the patient's t heard
F insurance group number (UB-9 t field 62) is re-
quired if a group number is shown on the patient's I) eard;j
rt verification number (UB-9 field 63) is required
if services have been verified pursuant to 74 of this ie If no
verification has been provided treatment authorization cdes (UB-92,
field 63) are required when authorization is required and granted;]
-(MM) principal diagnosis eede (UB-92 field 67) is re-
rTNN) diagnoses eedes other than principal diagnosis
eede (UB-9 fields 68 - 7-5) are required if there are diagnoses other
than the principal diagnosis;
0) admitting diagnosis eede (UB-92 field 76) is re-
ttquired38 TexReg 8120 November 15, 2013 Texas Register
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Texas. Secretary of State. Texas Register, Volume 38, Number 46, Pages 8023-8312, November 15, 2013, periodical, November 15, 2013; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth379973/m1/98/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.