ࡱ> ~yz{|}7 ybjbjUU U7|7|JKhl   jjjr>,:vp2cccwyyy>22g$* JE c"Uccc| j.|||c  w|cw||.x _ j \jBgO@k <: m, k|DThe UB-92 Claim Form is used to submit claims for outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics, chronic dialysis services and Adult Day Health Care). See UB-92 Completion: Inpatient Services in the Part 2 Inpatient Services Manual for billing instructions for services rendered to a registered hospital inpatient. If the patient is treated as an outpatient in a hospital different from the one in which the patient is registered, the services must be billed by the treating hospital using the UB-92 Claim Form with the appropriate facility type code (which is the first two digits in the Type of Bill field [Box 4]) for the outpatient facility. Most claims for outpatient services can also be submitted through Computer Media Claims (CMC). For CMC ordering and enrollment information, refer to the CMC section in the Part 1 manual. For additional billing information, refer to the UB-92 Special Billing Instructions for Outpatient Services, UB-92 Submission and Timeliness Instructions and UB-92 Tips for Billing: Outpatient Services sections in this manual. Note: Certain codes that providers enter on the UB-92 Claim Form changed as a result of the federally mandated Health Insurance Portability and Accountability Act (HIPAA). The following codes changed for Outpatient providers: Delay reason codes (previously billing limit exception codes) Condition codes Facility type and frequency codes (for purposes of this manual, the two-digit facility type code replaces the Medi-Cal Place of Service code) Admit type code (used only when designating emergency services) Claims for dates of service prior to September 22, 2003, must include the appropriate Medi-Cal local code. Claims for dates of service on or after September 22, 2003, must bill the appropriate national code. Claims for services rendered to the same recipient for dates of service both prior to and on or after September 22, 2003 must be submitted on separate claims (split billed), except when billing from-through services. Refer to the Code Correlation Guide at the end of this section to see the correlation between local and national codes. A handy HIPAA In Review guide also is included at the end of this section that summarizes important HIPAA implementation changes.  23 PATIENT CONTROL NO.5 FED. TAX NO.6 STATEMENT COVERS PERIOD FROM THROUGH 7 COV D. 8 N-C D. 9 C-I D. 10 L-R D.1112 PATIENT NAME13 PATIENT ADDRESSADMISSIONCONDITION CODES3114 BIRTHDATE15 SEX16 MS17 DATE18 HR19TYPE20 SRC21 DHR22STAT23 MEDICAL RECORD NO.2425262728293032OCCURRENCE33OCCURRENCE34OCCURENCE35OCCURRENCE36OCCURRENCE SPAN37CODE DATECODE DATECODE DATECODE DATECODEFROMTHROUGHAB C39VALUE CODES40VALUE CODES41 VALUE CODES CODEAMOUNTCODEAMOUNTCODEAMOUNT a b c d42 REV. CD.43 DESCRIPTION44 HCPCS / RATES45 SERV. DATE46 SERV. UNITS47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      00150 PAYER51 PROVIDER NO.52 REL INFO 53 ASG BEN54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 5657 DUE FROM PATIENT58 INSUREDS NAME59 P.REL60 CERT. -SSN-HIC.-ID NO.61 GROUP NAME62 INSURANCE GROUP NO.63 TREATMENT AUTHORIZATION CODES64 ESC65 EMPLOYER NAME66 EMPLOYER LOCATIONOTHER DIAG. CODES67 PRIN. DIAG CD.68 CODE69 CODE70 CODE71 CODE72 CODE73 CODE74 CODE75 CODE76 ADM. DIAG. CD.77 E-CODE7879 P.C. 80 PRINCIPAL PROCEDURE 81 OTHER PROCEDURE  OTHER PROCEDURECODEDATECODEDATECODEDATE82 ATTENDING PHYS. ID OTHER PROCEDURE OTHER PROCEDURE OTHER PROCEDURE CODEDATECODEDATECODEDATE83 OTHER PHYS. ID  FORMTEXT      84 REMARKS OTHER PHYS ID.  FORMTEXT      85 PROVIDER REPRESENTATIVE X86 DATE UB-92 HCFA - 1450I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.Figure 1. UB-92: Medi-Cal Required Fields for Outpatient Claims. Explanation of Form Items The following item numbers and descriptions correspond to the UB-92 Claim Form on the previous page. All items must be completed unless otherwise noted. Note: Items described as Not required by Medi-Cal may be completed for other payers, but are not recognized by the Medi-Cal claims processing system. Although the UB-92 Claim Form refers to each field as a Form Locator, Medi-Cal instructions will refer to it as a Box. Item Description 1. PROVIDER NAME, ADDRESS AND ZIP CODE. Enter the provider name, address and five-digit zip code. Please confirm that this information is correct before submitting claims. A telephone number is optional in this field. 2. UNLABELED. For FI use only. This field must be left blank on all claims submitted to Medi-Cal. 3. PATIENT CONTROL NUMBER. This is an optional field that will help you to easily identify a recipient on Resubmission Turnaround Documents (RTDs) and Remittance Advice (RAs). Enter the patients medical record number or account number in this field. A maximum of 20 numbers and/or letters may be used, but only 10 characters will appear on the RTD and RA. Refer to the Remittance Advice Details (RAD) Examples: Outpatient Services section in this manual for patient medical record number information. TYPE OF BILL. Enter the appropriate three-character type of bill code as specified in the National Uniform Billing Committee (NUBC) UB-92 Manual Billing Procedures. The type of bill code includes the two-digit facility type code and one-character claim frequency code. This is a required field when billing Medi-Cal.   Item Description 4. TYPE OF BILL (continued). The following facility type codes are a subset of the National Uniform Billing Committee (NUBC) UB-92 Manual Billing Procedures facility type codes commonly used by Medi-Cal. Use one of the following codes as the first two digits of the three-character type of bill code: Code Facility Type 11 Hospital Inpatient (Including Medicare Part A) 12 Hospital Inpatient (Medicare Part B only) 13 Hospital Outpatient 14 Hospital Other (For hospital referenced diagnostic services, or home health not under a plan of treatment). Use admit type 1 when billing for emergency services. 24 Skilled Nursing Clinic (For hospital referenced diagnostic services, or home health not under a plan of treatment) 25 Skilled Nursing Intermediate Care Level II (Level A) 26 Skilled Nursing Intermediate Care Level II (Level B) 27 Skilled Nursing Subacute (Use modifier -HB to indicate adult or -HA to indicate child) 33 Home Health Outpatient 34 Home Health Other (For hospital referenced diagnostic services, or home health not under a plan of treatment) 44 Religious Non-Medical Health Care Institutions, Hospital Inpatient Other (For hospital referenced diagnostic services, or home health not under a plan of treatment) 54 Religious Non-Medical Health Care Institutions, Post Hospital Extended Care Services Other (For hospital referenced diagnostic services, or home health not under a plan of treatment) Item Description 4. TYPE OF BILL (continued). Code Facility Type 64 Intermediate Care Other (For hospital referenced diagnostic services or home health not under a plan of treatment) 65 Intermediate Care Intermediate Care Level I 71 Clinic Rural Health 72 Clinic Hospital Based or Independent Renal Dialysis Center 73 Clinic Free Standing 74 Clinic Outpatient Rehabilitation Facility (ORF) 75 Clinic Comprehensive Outpatient Rehabilitation Facility (CORF) 76 Clinic Community Mental Health Center 79 Clinic Other 81 Special Facility Hospice (non-hospital based) 83 Special Facility Ambulatory Surgery Center 86 Special Facility Residential Facility 89 Special Facility Other Notes: Only one facility type may be billed on each claim. Outpatient services not logically compatible with the facility type identified on the claim must be billed on a separate claim. Refer to the Code Correlation Guide at the end of this section for information about claims for services rendered prior to September 22, 2003. For additional information about the relationship between facility type codes and other fields, such as admit type and modifiers, refer to the HIPAA In Review guide at the end of this section. Item Description 4. TYPE OF BILL (continued). Clinics and outpatient hospitals use one of the following codes as the first two digits of the three-character type of bill code: Provider Type Facility Type AIDS Waiver Agency 13, 33, 79 Chronic Dialysis Clinic 72 Community Hospital, Outpatient 13 Community Mental Health Clinic 76 Employer/Employee Clinic 79 Exempt from Licensure Clinic 79 Free Clinic 79 Home Health Agency 33 Local Educational Agency 89 Multispecialty Clinic 79 Rehab Clinic 74 Rehab Clinic (Comprehensive) 75 Rural Health Clinic 71 Surgical Clinic 73, 79 Note: Refer to the Code Correlation Guide at the end of this section for information about claims for services rendered prior to September 22, 2003. Item Description 5. FEDERAL TAX NUMBER. Not required by Medi-Cal. 6. STATEMENT COVERS PERIOD (From-Through). Not required by Medi-Cal. 7. COVERAGE DAYS. Not required by Medi-Cal. 8. NON-COVERED DAYS. Not required by Medi-Cal. 9. CO-INSURANCE DAYS. Not required by Medi-Cal. 10. LIFETIME RESERVE DAYS. Not required by Medi-Cal. 11. UNLABELED. Not required by Medi-Cal. Item Description 12. PATIENT NAME. Enter the patients last name, first name and middle initial (if known). Avoid nicknames or aliases. Newborn Infant When submitting a claim for a newborn infant using the mothers ID number, enter the infants name in Box 12. If the infant has not yet been named, write the mothers last name followed by Baby Boy or Baby Girl (example: Jones, Baby Girl). If billing for newborn infants from a multiple birth, each newborn must also be designated by number or letter (example: Jones, Baby Girl, Twin A) on separate claims. Enter the infants date of birth and sex in Boxes 14 and 15. Enter the mothers name in Box 58 (Insureds Name) and enter 03 (CHILD) in box 59 (Patients Relationship to Insured). Organ Donors When submitting a claim for a patient donating an organ to a Medi-Cal recipient, enter the donors name, date of birth and sex in the appropriate boxes. Enter the Medi-Cal recipients name in Box 58 (Insureds Name) and enter 11 (DONOR) in Box 59 (Patients Relationship to Insured). 13. PATIENT ADDRESS. Not required by Medi-Cal. 14. BIRTHDATE. Enter the patients date of birth in an eight-digit MMDDYYYY [Month, Day, Year] format (for example, September 16, 1967 = 09161967). If the recipients full date of birth is not available, enter the year preceded by 0101. (For newborns and organ donors, see Item 12.) Item Description 15. SEX. Use the capital letter M for male, or F for female. Obtain the sex indicator from the Benefits Identification Card. (For newborns and organ donors, see Item 12 on a previous page.) 16. PATIENT MARITAL STATUS. Not required by Medi-Cal. 17. ADMISSION DATE. Not required by Medi-Cal. 18. ADMISSION HOUR. Not required by Medi-Cal. 19. TYPE OF ADMISSION. Enter admit type code 1 in conjunction with facility type 14 when billing for emergency room-related services. Not required by Medi-Cal for any other use: Emergency 1 See Emergency Certification under Condition Code (Item 24 30) on a following page for additional information. Item Description 20. SOURCE OF ADMISSION. Not required by Medi-Cal. 21. DISCHARGE HOUR. Not required by Medi-Cal. 22. STATUS. Not required by Medi-Cal. 23. MEDICAL RECORD NUMBER. Not required by Medi-Cal. This number will not appear on the RTD or RA for recipient identification. The Patient Control Number (Item 3) will appear on the RTD and RA. Item Description 24 30. CONDITION CODES. Condition codes are used to identify conditions relating to this bill that may affect payer processing. Although the Medi-Cal claim processing system only recognizes the condition codes below, providers may include codes accepted by other payers in Boxes 24 30. The claims processing system will ignore all codes not applicable to Medi-Cal. Condition codes should be entered from left to right in numeric-alpha sequence starting with lowest value. For example, if billing for three condition codes, A1, 80 and 82, enter 80 in Box 24, 82 in Box 25 and A1 in Box 26. See Figure 2.    Item Description 24 30. CONDITION CODES (continued). Applicable Medi-Cal codes are: OTHER COVERAGE. Enter code 80 if recipient has other coverage. Other Health Coverage (OHC) includes insurance carriers as well as Prepaid Health Plans (PHPs) and Health Maintenance Organizations (HMOs) that provide any of the recipients health care needs. Eligibility under Medicare or a Medi-Cal managed care plan is not considered other coverage and is identified separately. Medi-Cal policy requires that, with certain exceptions, providers must bill the recipients other health insurance coverage prior to billing Medi-Cal. (For details about OHC, refer to the Other Health Coverage (OHC) Guidelines for Billing section in the Part 1 manual.) EMERGENCY CERTIFICATION. Enter code 81 if billing for emergency services. An Emergency Certification Statement must be attached to the claim or entered in the Remarks area. The statement must be signed by the attending provider. It is required for all OBRA/IRCA recipients and any service rendered under emergency conditions that would otherwise have required prior authorization such as emergency services by allergists, podiatrists, medical transportation providers, portable X-ray providers, psychiatrists and out-of-state providers. These statements must be signed and dated by the provider and must be supported by a physician, podiatrist or dentists statement describing the nature of the emergency, including relevant clinical information about the patients condition. A mere statement that an emergency existed is not sufficient. If the Emergency Certification Statement will not fit in this area, attach the statement to the claim. OUTSIDE LABORATORY. Enter code 82 if this claim includes charges for laboratory work performed by a licensed laboratory. Outside laboratory (facility type 89) refers to a laboratory not affiliated with the billing provider. State in the Remarks area that a specimen was sent to an unaffiliated laboratory. Item Description 24 30. CONDITION CODES (continued). FAMILY PLANNING/CHDP. Enter code AI or A4 if the services rendered are related to Family Planning (FP). Enter code A1 if the services rendered are Early and Periodic Screening, Diagnosis and Treatment (EPSDT)/Child Health and Disability Prevention (CHDP) screening related. Leave blank if not applicable. Code Description A1 EPSDT/CHDP A4 Family Planning AI Sterilization/Sterilization Consent Form (PM 330) must be attached if code AI is entered Note: Refer to the Code Correlation Guide at the end of this section for information about claims for services rendered prior to September 22, 2003. See Family Planning and Sterilization sections in the appropriate Part 2 manual for further information. Item Description 24 30. CONDITION CODES (continued). MEDICARE STATUS. Medicare status codes are required for Charpentier claims. In all other circumstances, these codes are optional; therefore, providers may leave this area of the Condition Codes fields (Boxes 24 30) blank on the UB-92 Claim Form. The Medicare status codes are: Code Description Y0 Under 65, does not have Medicare coverage * Y1 Benefits exhausted * Y2 Utilization committee denial or physician non-certification * Y3 No prior hospital stay * Y4 Facility denial * Y5 Non-eligible provider * Y6 Non-eligible recipient * Y7 Medicare benefits denied or cut short by Medicare intermediary Y8 Non-covered services * Y9 PSRO denial * Z1 Medi/Medi Charpentier: Benefit Limitations * Z2 Medi/Medi Charpentier: Rates Limitations * Z3 Medi/Medi Charpentier: Both Rates and Benefit Limitations * Documentation required. Refer to the Medicare/Medi-Cal Crossover Claims: Outpatient Services section in the appropriate Part 2 manual for more information. Item Description 31. DELAY REASON. Enter one of the following delay reason codes and include the required documentation if there is an exception to the six-months-from-the-month-of-service billing limit. CodeDescriptionDocumentation1Proof of Eligibility unknown or unavailableRemarks/ Attachment3Authorization delaysRemarks4Delay in certifying providerRemarks5Delay in supplying billing formsRemarks6Delay in delivery of custom-made appliancesRemarks7Third party processing delayAttachment10Administrative delay in prior approval process (decision appeals)Attachment11Other (no reason)None11Other (theft, sabotage)Attachment15Natural disasterAttachment Refer to the UB-92 Submission and Timeliness Instructions section in this manual, Figures 2a & 2b, for detailed information about codes and documentation requirements. Note: Refer to the Code Correlation Guide at the end of this section for information about claims for services rendered prior to September 22, 2003. Item Description 32 35 OCCURRENCE CODES AND DATES. Occurrence codes A B. and dates are used to identify significant events relating to a bill that may affect payer processing. Occurrence codes and dates should be entered from left to right, top to bottom in numeric-alpha sequence starting with the lowest value. For example, if billing for two occurrence codes 24 (accepted by another payer) and 05 (accident/no medical or liability coverage), enter 05 in Box 32A and 24 in Box 33A. See Figure 3. 32 OCCURRENCE33 OCCURRENCE34 OCCURRENCE35 OCCURRENCECODEDATECODEDATECODEDATECODEDATE0510200024113000Line ALine B Figure 3. UB-92 Claim Form: Occurrence Codes Example. Although the Medi-Cal claim processing system will only recognize the codes on the following page, providers may include codes and dates billed to other payers in Boxes 32 35. The claims processing system will ignore all codes not applicable to Medi-Cal. Item Description 32 35. OCCURRENCE CODES AND DATES (continued). Applicable Medi-Cal codes are: ACCIDENT/INJURY EMP./NON-EMP./RELATED AND DATE. If condition is an accident or injury and was employment or non-employment related, complete this field. If not an accident or injury, leave blank. Enter code 04 (accident/employment related) in fields 32 through 35 if the accident or injury was employment related. Enter one of the following codes if the accident or injury was non-employment related: Code Description 01 Accident/medical coverage 02 No-fault insurance involved Including auto accident/other 03 Accident/tort liability 05 Accident/no medical or liability coverage 06 Crime victim In six-digit MMDDYY (Month, Day, Year) format, enter the date of accident/injury in the corresponding box. 36A B. OCCURRENCE SPAN CODES AND DATES. Not required by Medi-Cal. 37A C. INTERNAL CONTROL NUMBER (ICN)/DOCUMENT CONTROL NUMBER (DCN). Not required by Medi-Cal. 38. RESPONSIBLE PARTY NAME AND ADDRESS. Not required by Medi-Cal. Item Description 39 41A D. VALUE CODES AND AMOUNT. Patients Share of Cost. Value codes and amounts should be entered from left to right, top to bottom in numeric-alpha sequence starting with lowest value. For example, if billing for two value codes 30 (accepted by another payer) and 23 (accepted by Medi-Cal), enter 23 in Box 39A and 30 in Box 40A. See Figure 4. Value codes and amounts are used to relate amounts to data elements necessary to process the claim. Although the Medi-Cal claims processing system only recognizes code 23, providers may include codes and dates billed to other payers in Boxes 39 41. The claims processing system will ignore all codes not applicable to Medi-Cal.  Enter code 23 and the amount of the patients Share of Cost for the procedure or service if applicable. Do not enter a decimal point (.), dollar sign ($), positive (+) or negative (-) sign. Enter full dollar amount and cents even if the amount is even (for example, if billing for $100, enter 10000, rather than 100). For more information about Share of Cost, see the Share of Cost: UB-92 for Outpatient Services section in the appropriate Part 2 manual. Item Description REVENUE CODE. Enter code 001 on the last detail line or on line 23 in this box to designate the total charge line. Refer to the two-color example on a previous page for an illustration. 43. DESCRIPTION. This optional field will help you separate and identify the descriptions of each service. The description must identify the particular service code indicated in the HCPCS/Rates field (Box 44). For more information, refer to the CPT-4 code book. 44. HCPCS/RATES. Enter the applicable procedure code (CPT-4 or HCPCS) and modifier(s). Note that the descriptor for the code must match the procedure performed and that the modifier(s) must be billed appropriately. Attach reports to the claim for By Report codes, complicated procedures (modifier -22) and unlisted services. Reports are not required for routine procedures. Non-payable CPT-4 codes are listed in the TAR and Non-Benefit List: Codes (10000 99999) sections in the appropriate Part 2 manual. 44. HCPCS/RATES45.46.47.48.49.XXXXXLTRTRPY4 Figure 5. Multiple Modifiers. Up to four modifiers may be entered on outpatient UB-92 claims. Modifiers one and two (-LT and -RT in the above example) must be billed immediately following the HCPCS code in the HCPCS/Rates field (Box 44) with no spaces. The remaining two modifiers (-RP and -Y4 in the above example) are entered in Box 49 with no spaces. Medicare/Medi-Cal If billing for services to a recipient with both Medicare and Recipients Medi-Cal, refer to the Medicare Non-Covered Services sections in the appropriate Part 2 Outpatient Services manual to check the list of Medicare non-covered services codes. Only those services listed in a Medicare Non-Covered Services section may be billed directly to Medi-Cal. All others must be billed to Medicare first. For a listing of modifier codes, refer to the Modifiers: Approved List section in the appropriate Part 2 manual. Item Description 45. SERVICE DATE. Enter the date the service was rendered in six-digit, MMDDYY (Month, Day, Year) format, for example, June 24, 2003 = 062403. Note: The from date in this field determines whether you must enter national codes or local Medi-Cal codes on your claim. Refer to the Code Correlation Guide and HIPAA In Review guide at the end of this section for information about the specific codes you must bill with a national value for dates of service on or after September 22, 2003. From-Through Billing For From-Through billing instructions, refer to the UB-92 Special Billing Instructions for Outpatient Services section in this manual. 46. SERVICE UNITS. Enter the actual number of times a single procedure or item was provided for the date of service. Note: Although this is a seven-digit field, Medi-Cal allows only two digits in this field. If billing for more than 99 units, enter 99 on the first line and any additional units on subsequent lines. 47. TOTAL CHARGES. In full dollar amount, enter the usual and customary fee for the service billed. Do not enter a decimal point (.) or dollar sign ($). Enter full dollar amount and cents even if the amount is even (for example, if billing for $100, enter 10000 not 100). If an item is a taxable medical supply, include the applicable state and county sales tax. Note: Medi-Cal cannot process credits or adjustments on the UB-92 form. Refer to the CIF Completion and CIF Special Billing Instructions for Outpatient Services sections in the appropriate Part 2 manual for information regarding claim adjustments. Enter the Total Charge for all services on the last detail line or on line 23. Enter code 001 in Box 42 (Revenue Code) to indicate this is the total charge line (refer to Item 42 on a preceding page). Item Description 48. NON-COVERED CHARGES. Not required by Medi-Cal. 49. UNLABELED. As appropriate, enter the third and fourth modifiers without spaces. Note: Providers may enter up to 22 lines of detail data (Items 42 49). It is also acceptable to skip lines between data. To delete a line, mark through the boxes as shown in Figure 6. Be sure to draw a thin line through the entire detail line using a blue or black ballpoint pen.  Figure 6. UB-92 Claim Form: Line Deletion Example. Item Description 50A C. PAYER. Enter O/P MEDI-CAL to indicate the type of claim and payer.       Important: When completing Boxes 50 66 (excluding Boxes 56 and 57) enter all information related to the information in Box 50 (Payer) on the same line (for example, Line A, B or C) in order of payment (Line A: other insurance, Line B: Medicare, Line C: Medi-Cal). Do not enter information on Lines A and B for other insurance or Medicare if payment was denied by these carriers. Item Description 50A C. PAYER (continued). Figure 8 shows payer-related information for other insurance and Medi-Cal. The name of the other insurance is entered on Line A of Box 50, with the amount paid by Other Coverage on Line A of Box 54 (Prior Payments). All information related to the Medi-Cal billing is entered on Line B of these boxes. Be sure to enter the corresponding prior payments on the correct line. Note: If Medi-Cal is the only payer billed, all information in Boxes 50 66 should be entered on Line A. Reminder: If the recipient has Other Health Coverage, the insurance carrier must be billed prior to billing Medi-Cal. Refer to the HIPAA In Review guide at the end of this section when billing for dates of service prior to September 22, 2003.  50 PAYER 51 PROVIDER NO.52 REL 53 ASG INFO BEN 54 PRIOR PAYMENTS 55 EST. AMOUNT DUEAABC INSURANCE5000BO/P MEDI-CALHSP1234565000C  Item Description 51A C. PROVIDER NUMBER. Enter your Medi-Cal provider number; be sure to include all nine characters of the number. CHECK DIGIT. A check digit is used by EDS to verify accurate input of the Medi-Cal provider number. Enter the check digit immediately following the last digit of the provider number. The check digit is not a required item. However, it is recommended to ensure payment for the claim is made to the correct provider. If you do not know your check digit, contact the EDS Provider Support Center at 1-800-541-5555. Provider When a provider is assigned a new Medi-Cal provider Number Change number by the DHS Provider Master File Unit, a beginning date is listed. When billing for dates of service on or after this beginning date, the new number should be used. When billing for dates of service prior to this beginning date, the old Medi-Cal provider identification number is to be used. Refer to the Provider Guidelines section in the Part 1 manual for provider enrollment contact information. Billing Services Providers using a billing service should notify the service to amend its records so that the correct provider number for the date of service will appear on the claim. 52A C. RELEASE OF INFORMATION CERTIFICATION INDICATOR. Not required by Medi-Cal. Item Description 53A C. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR. Not required by Medi-Cal. 54 A B. PRIOR PAYMENT (Other Coverage). Enter the full dollar amount of payment received from Other Coverage on the same line as the Other Coverage payer (Box 50). Do not enter a decimal point (.), dollar sign ($), positive (+) sign or negative (-) sign. Leave blank if not applicable. Note: For instructions about completing this field for Medicare/Medi-Cal recipients, refer to the Medicare/Medi-Cal Crossover Claims: Outpatient Services section in the appropriate Part 2 manual. 55A C. ESTIMATED AMOUNT DUE (Net Amount Billed). In full dollar amount, enter the difference between Total Charges and any deductions (for example, patients Share of Cost and/or Other Coverage). Do not enter a decimal point (.) or dollar sign ($). Total Charges (Box 47) Revenue code 001 (Minus) Deductions Share of Cost (Box 39, 40 or 41A D/Value code 23) and Other Coverage (Box 54A or B) (Equals) = Net Billed (Boxes 55A C) 56. UNLABELED. Not required by Medi-Cal. Note: For instructions about completing this field for Medicare/Medi-Cal recipients, refer to the Medicare/Medi-Cal Crossover Claims: Outpatient Services section in the appropriate Part 2 manual. 57. UNLABELED. Not required by Medi-Cal. Item Description 58A C. INSUREDS NAME. If billing for an infant using the mothers ID or for an organ donor, enter the Medi-Cal recipients name here and the patients relationship to the Medi-Cal recipient in Box 59 (Patients Relationship to Insured). See Item 12 on a previous page in this section. This box is not required by Medi-Cal except under these circumstances. 59A C. PATIENTS RELATIONSHIP TO INSURED. If billing for an infant using the mothers ID or for an organ donor, enter the patients relationship to the Medi-Cal recipient (for example, 03 [CHILD] or 11 [DONOR]). See Item 12 on a previous page in this section. This box is not required by Medi-Cal except under these circumstances. 60A C. CERT.SSNHICID NUMBER. Enter the 14-character recipient ID number as it appears on the Benefits Identification Card (BIC) or paper Medi-Cal ID card. Note: Medi-Cal does not accept HIC Numbers. Newborn Infant When submitting a claim for a newborn infant for the month of birth or the following month, enter the mothers ID number in this field. (For more information, see Item 12 on a previous page.) Item Description 61A C. INSURED GROUP NAME. Not required by Medi-Cal. 62A C. INSURANCE GROUP NUMBER. Not required by Medi-Cal. 63A C. TREATMENT AUTHORIZATION CODES. For services requiring a Treatment Authorization Request (TAR), enter the 11-digit TAR Control Number. It is not necessary to attach a copy of the TAR to the claim. Recipient information on the claim must match the TAR. Multiple claims must be submitted for services, which have more than one TAR. Only one TAR Control Number can cover the services billed on any one claim. Note: TAR and non-TAR procedures should not be combined on the same claim. 64A C. EMPLOYMENT STATUS CODE. Not required by Medi-Cal. 65A C. EMPLOYER NAME. Not required by Medi-Cal. 66A C. EMPLOYER LOCATION. Not required by Medi-Cal. 67. PRINCIPAL DIAGNOSIS CODE. Enter all letters and/or numbers of the ICD-9-CM code for the primary diagnosis, including fourth and fifth digits if present. Do not enter a decimal point when entering the code. 68. OTHER DIAGNOSIS CODE. If applicable, enter all letters and/or numbers of the secondary ICD-9-CM code, including fourth and fifth digits if present. Do not enter a decimal point when entering the code. Item Description 69. 75. OTHER DIAGNOSIS CODES. Not required by Medi-Cal. 76. ADMITTING DIAGNOSIS. Not required by Medi-Cal. 77. EXTERNAL CAUSE OF INJURY CODE (E-CODE). Not required by Medi-Cal. 78. UNLABELED. Not required by Medi-Cal. 79. PROCEDURE CODING METHOD USED. Not required by Medi-Cal. 80. PRINCIPAL PROCEDURE CODE AND DATE. Not required by Medi-Cal. 81. OTHER PROCEDURE CODES AND DATES. Not required by Medi-Cal. 82. ATTENDING PHYSICIAN ID (Referring/Prescribing Provider). On the upper line of Box 82, enter the Medi-Cal provider number of the referring or prescribing physician. This field is mandatory for radiologists. If he or she is not a Medi-Cal provider, enter the state license. Do not use a group provider number. See Figure 9. Item Description 83A. OTHER PHYSICIAN ID (Rendering Provider). On the upper line of Box 83A, enter the individual nine-digit Medi-Cal provider number of the facility in which the recipient resides or of the physician actually providing services. Only one rendering provider number may be entered per claim form. Do not use a group provider number or State license number. See Figure 9 below. 83B. Not required by Medi-Cal.    Item Description 84. REMARKS. Use this area for procedures that require additional information, justification or an Emergency Certification Statement. The Emergency Certification Statement is required for all OBRA/IRCA recipients and any service rendered under emergency conditions that would otherwise have required prior authorization such as emergency services by allergists, podiatrists, medical transportation providers, portable X-ray providers, psychiatrists and out-of-state providers. These statements must be signed and dated by the provider and must be supported by a physician, podiatrist or dentists statement describing the nature of the emergency, including relevant clinical information about the patients condition. A mere statement that an emergency existed is not sufficient. If the Emergency Certification Statement will not fit in this area, attach the statement to the claim. 85 86. SIGNATURE OF PROVIDER and DATE. The claim must be signed and dated by the provider or a representative assigned by the provider. Use black ballpoint pen only. An original signature is required on all paper claims. The signature must be written, not printed. Stamps, initials or facsimiles are not acceptable. Signature does not have to be on file at EDS. ub comp op  PAGE 2 ub comp op UB-92 Completion: Outpatient Services  PAGE 1 2 Forms: Reorder Request ___ 2000 2 UB-92 Completion: Outpatient Services Outpatient Services 349 November 2003 Forms: Reorder Request Overview  PAGE 1 2 Forms: Reorder Request Overview ___ 2000 ub comp op  PAGE 2 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 3 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 4 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op 5 2 UB-92 Completion: Outpatient Services Outpatient Services 351 January 2004 ub comp op  PAGE 6 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 7 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 8 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 9 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 10 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 11 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 12 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 13 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 14 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 15 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 16 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 17 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 18 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 20 ub comp op  PAGE 21 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 371 September 2005 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 22 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 23 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 24 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 25 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 26 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op 25 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 372 October 2005 ub comp op  PAGE 28 2 UB-92 Completion: Outpatient Services Outpatient Services 370 August 2005 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 29 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 30 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 ub comp op  PAGE 31 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 ub comp op  PAGE 30 2 UB-92 Completion: Outpatient Services Outpatient Services 347 September 2003 2 UB-92 Completion: Outpatient Services Outpatient Services ___ ______2003 42 REV. CD.43 DESCRIPTION44 HCPCS/RATES45 SERV. DATE46 SEEMERGENCY ROOM USEZ75011120002EMERGENCY ROOM USEZ75021130002PANEL TEST80018TC1130001AMINO ACID NITROGEN82126901130001 Figure 2. UB-92 Claim Form: Condition Codes Example. CONDITION CODES242526272829308082A1 Line A Line B Line C Line D 39 VALUE CODES40 VALUE CODES41 VALUE CODESCODEAMOUNTCODEAMOUNTCODEAMOUNT2350003010000 Figure 4. UB-92 Claim Form: Value Codes Example. Use CAPITAL letters only A B C O/P MEDI-CAL 50 PAYER 4. TYPE OF BILL Figure 7. UB-92 Claim Form: Payer Example. Figure 8. UB-92 Claim Form: Payer Related Information Example. 83 OTHER PHYS. ID 00A123456 A B Figure 9. UB-92 Claim Form: Referring, Prescribing and Rendering Provider. OTHER PHYS. ID DATE SIGNATURE NA REMARKS/EMERGENCY CERTIFICATION RENDERING PROV. NO. NA NA NA NA NA NA NA NA NA NA NA NA NA REFERRING/PRESCRIBING PROV. NO NA NA NA NA NA NA NA NA NA NA SEC. ICD9 PRIM ICD9 NA NA NA TAR CONTROL NUMBER NA NA NA NA MEDI-CAL ID NUMBER NA NA PROVIDER NO. O/P MEDI-CAL NET AMOUNT BILLED NA NA OTHER COVERAGE TOTAL CHARGES NA UNIT OF SERVICE DATE OF SERVICE PROC CD MOD1&2 DESCRIPTION OF SERVICE REVENUE CODE MODIFIER 3&4 SERVICE CHARGE VALUE CODES AND AMOUNTS OCCURRENCE CODES AND DATES NA NA NA TYPE TYP DOB SEX NA NA NA NA NA CONDITION CODES DELAY REASON CODE PATIENTS ADDRESS PATIENTS NAME NA NA NA NA NA NA NA NA NA TYPE OF BILL CODE PROVIDER NAME/ADDRESS/ZIP CODE A B C a b c d 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 A B C A B C a b a b a b 1 PATIENT ACCOUNT NUMBER LEAVE BLANK 734 4 TYPE OF BILL 82 ATTENDING PHYS. 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