QUEST Integration – Instructions for Completing the UB-04 Claim Form

Provider Information:

Line 1:Provider name (25 positions, alpha)

Line 2:Street address (25 positions, alphanumeric)

Line 3:City (positions 1-12, alpha), state – standard 2-character postal abbreviation (positions 14-15, alpha), ZIP code (positions 17-25, numeric), ZIP+4 is acceptable, but not required for hard-copy claims.

Payee Information:

Not required by HMSA QUEST Integration

Type of bill (TOB) (4 positions, alphanumeric)

Supplemental information related to type of bill:

When specific types of bill are used, be sure to complete the corresponding form locators as described below:

1. Form locator 12 is required for all inpatient and home health claims.
2. Form locator 13 is required for all inpatient claims.
3. Form locator 14 is required on all claims.
4. Form locator 16 is required on admit through discharge claims. Should also be used on interim – last inpatient claims. Also required on claims for observation care, ambulatory surgery center (ASC) and emergency room (ER).
5. Form locator 17 is required for QUEST Integration claims.
6. Form locator 69 is required on hospital inpatient Parts A and B claims and on claims for hospital swing beds and SNF inpatient Part A claims.
7. Form locators 70a-c are required on claims for hospital outpatient services and services performed in a critical access hospital (CAH) when Type of Admission is emergency, urgent or trauma center AND the service is emergency room, urgent care clinic or observation room. May be reported on other outpatient and CAH bills as needed to provide additional information to support medical necessity.
8. Form locators 18 and 64 are required for replacement (XXX7), resubmission (XXX7) and void (XXX8) claims.

Federal tax number (10 positions including hyphen, numeric)

If used, enter code in the format NN-NNNNNNN.

Statement covers period (12 positions, numeric)

From: Enter the first service date covered by the bill. Enter the date in MMDDYY format. Example: For March 3, 2007, enter the date as 030307.

Through: Enter the last service date covered by the bill. Enter the date in MMDDYY format. Example: For March 5, 2007, enter the date as 030507.

Notes:

1. Do not use slash marks.
2. Do not leave blank spaces.
3. The through date must occur after the date.
4. For services with a single date of service (e.g., emergency room), the from date and the through date should be the same date.
5. Do not bill for future services (i.e., services that have not yet taken place as of this billing).

Unlabeled field

Reserved for assignment by NUBS

Patient identifier (19 positions)

Not required by HMSA

Patient name ( 29 positions, alpha)

Enter the last name, first name and middle initial of the patient. Capital letters are preferred. For example John J. Smith would be entered as: SMITH, JOHN J.

Notes:

1. Last name should be entered exactly as shown on the membership card; e.g., VAN PLATT, HUGHES-CHING, MACDONALD.
2. Titles, such as Mr. or Dr., should not be recorded as data elements.
3. To add a suffix (e.g., Jr. or III) to a name, write the last name, leave a space and write the suffix exactly as shown on the membership card. Then write the first name as in CARTER JR., DAVID W.

Country code (2 positions, alpha)

Enter the country code if other than the U.S.

Patient birthdate (8 positions, numeric)

Enter the patient’s date of birth in MMDDCCYY format. For example, February 14, 1964, would be entered as 02141964.

Notes:

1. Do not use slash marks.
2. Do not leave blank spaces.

Patient sex (1 position, alpha)

Notes:

1. Enter M (male) or F (female), as appropriate.
2. Do not use U (unknown).

Admission date/start of care date (6 positions, numeric)

Notes:

1. For inpatient services and hospice: Enter the date the patient was admitted.
2. For home health: Enter the date services began.

3. For outpatient services: Enter the date care was started.

   The date should be entered in MMDDYY format. For example, April 23, 2007 would be entered as 042307.

   1. Do not use slash marks.
   2. Do not leave blank spaces.

Admission hour (2 positions, numeric)

Enter the hour during which the patient was admitted for ambulatory surgery center (ASC), emergency room (ER), and inpatient services.

The hour should be entered in military time. Minutes are not indicated. For example, for a patient admitted anytime between 2:00 p.m. and 2:59 p.m., the admission hour would be 14.

Note: Not required for SNF Part A claims.

Source of referral for admission or visit (1 position, alphanumeric)

Enter a code indicating the source of referral for this admission/visit for inpatient or outpatient services.

Discharge hour (2 positions, numeric)

Required on admit through discharge claims. Should also be used on interim – last inpatient claims. Also required on claims for observation care, ambulatory surgery center (ASC) and emergency room (ER).

Enter the hour during which the patient was discharged.

The hour should be entered in military time. Minutes are not indicated. For example, for a patient discharged anytime between 2:00 pm and 2:59 pm, the discharge hour would be 14.

Patient discharge status (2 positions, numeric)

Note: The NUBC Official UB-04 Data Specifications Manual includes a number of questions and answers related to the appropriate use of these codes. Please refer to the manual for detailed answers to billing questions.

1. The patient status must match the type of bill code in field #04. i.e.; if billing for a continuing interim claim the patient status must be still a patient.

Condition codes (11 fields, 2 positions each, alphanumeric)

Required for replacement, resubmission and void claim.

Condition codes (11 fields, 2 positions each, alphanumeric)

Required only if applicable.

Untitled

Reserved for assignment by NUBC

Occurrence code/date (8 fields with 2-position codes [alphanumeric] and 6-position dates [numeric])

Required only if applicable.

Notes:

1. Enter codes and associated dates defining significant events related to this bill.
2. Occurrence codes and dates should be completed from left to right and then from top to bottom. 31a, 32a, 33a and 34a should be completed before 31b, 32b, 33b and 34b.
3. If more than eight occurrence codes are needed to adequately describe varying situations, additional occurrence codes may be entered in the occurrence span fields. This can be accomplished by using form locators 35a FROM, 36a FROM, 35b FROM and 36b FROM.
4. Form locator 81 may also be used for additional overflow.
5. Dates should be entered in MMDDYY format. Thus, April 24, 2007, would be entered as 042407.
   1. Do not use slash marks in dates.
   2. Do not leave blank spaces in dates.

Occurrence span (8 fields with 2-position codes [alphanumeric] and 6-position dates [numeric])

Required when there is an occurrence span code and date combination that applies to this claim.

Notes:

1. Occurrence span codes and dates should be completed from left to right and then from top to bottom. 35a and 36a should be completed before 35b and 36b.
2. Enter occurrence span codes in the sequence shown in the NUBC Official UB-04 Data Specifications Manual.
3. Both a from and through date must be entered.
4. There are sufficient fields to enter four occurrence span codes and dates. If additional fields are required, Form locator 81 can be used as overflow.
5. For long term care stays, provide the appropriate code for the level of care and the applicable dates for the level of care.

Occurrence span (4 fields with 2-position codes [alphanumeric] and 6-position dates [numeric])

Required when there is an occurrence span code and date combination that applies to this claim.

Notes:

1. Occurrence span codes and dates should be completed from left to right and then from top to bottom. 35a and 36a should be completed before 35b and 36b.
2. Enter occurrence span codes in the sequence shown in the NUBC Official UB-04 Data Specifications Manual.
3. Both a from and through date must be entered.
4. There are sufficient fields to enter four occurrence span codes and dates. If additional fields are required, Form locator 81 can be used as overflow.

Untitled

Reserved for assignment by NUBC

Responsible party name and address

If a third party is responsible for the bill, provide the party's name and address

Value code(s) (12 fields with 2-position codes [alphanumeric] and 9-position amounts [numeric])

Enter value codes and corresponding amounts that apply to this claim.

Notes:

1. When multiple value codes/amounts apply, enter the codes in the following sequence:

   39a, 40a, 41a

   39b, 40b, 41b

   39c, 40c, 41c

   39d, 40d, 41d

2. If additional space is needed, form locator 81 may be used as overflow.

   Sections. There are two sections to this field.

   Enter an alphanumeric code in the first section. If more than one code is used, enter the codes in sequence, as listed in the NUBC Official UB-04 Data Specifications Manual.

   Enter an amount in the second section (dollars & cents, or a whole-number/non-dollar number). Follow these guidelines:

   1. Enter dollars & cents right justified. The cents should be to the right of the delimiter and the dollars should be to the left of the delimiter, as would normally be expected.
   2. For whole-number/non-dollar amounts, enter the number in a position that is right-justified before (to the left of) the delimiter.
   3. For whole-number/non-dollar amounts, do not add zeros to fill in the spaces following the delimiter.
   4. Do not enter negative numbers in the amount field.

Revenue code(4 positions)

Enter a numeric revenue code(s) described in the NUBC Official UB-04 Data Specifications Manual.

Notes:

Revenue code categories are four digits with an “x” in the fourth position to denote the subcategory number. Subcategories are numbered from 0 to 9 and provide more information about the services being rendered.

1. When reporting the revenue code, a number (0-9) must be entered in position 4. Do not report an “x” in position 4.
2. Each service should be assigned a revenue code.
3. Services provided on different service dates should be listed on separate service lines.
4. Revenue codes for outpatient services should be listed in ascending numeric order, by date of service.
5. Revenue code 0001 should be entered on line 23. See directions for line 23 below.
6. For inpatient services involving multiple services for the same item, providers should aggregate the services under the assigned revenue code and then report the total number of units that represent those services.
7. For outpatient services refer to the NUBC Official UB-04 Data Specifications Manual.If a “Y” is indicated in the HCPCS column next to the corresponding revenue code, providers should report the appropriate HCPCS Level I or Level II code for the service along with the date of service and the revenue code.

If multiple E/M services, report each service on a separate service line. If more than one E/M service is performed on the same service date, use condition code “G0” to indicate a “distinct medical visit” was performed.

Description (of revenue code) (24 positions, alphanumeric)

Enter the standard abbreviation(s) for the revenue code(s) listed in form locator 42, as described in the NUBC Official UB-04 Data Specifications Manual.

HCPCS/rate/HIPPS code (14 positions)

Required as follows:

HCPCS and HIPPS rate codes (alphanumeric, left justify)

Required for outpatient claims when an appropriate HCPCS Level I or Level II code or HIPPS code exists for this service and the NUBC Official UB-04 Data Specifications Manual indicates that one is required.If a “Y” is indicated in the HCPCS column next to the corresponding revenue code in the manual, providers should report the appropriate HCPCS code.

Accommodation rates (numeric, right justify)

Required when a room & board revenue code is reported.

HCPCS Level I and Level II modifiers (alphanumeric, place following the HCPCS code)

Required when a modifier clarifies or improves the reporting accuracy of the associated procedure code.

Notes:

1. The HCPCS field consists of 5 positions for the base code plus 8 positions for up to 4 HCPCS modifiers, 2 digits each.
2. The HIPPS rate codes were developed by CMS to determine payment rates under the prospective payment systems including resource utilization groups (RUGs), home health resource groups (HHRGs) and case mix groups (CMGs).

Service date (6 positions, numeric)

Required for outpatient services.

Notes:

1. Each service performed on a different service date must be reported on a separate service line.
2. Enter the date in MMDDYY format. Example, for March 5, 2007, enter the date as 030507.
   1. Do not use slash marks.
   2. Do not leave blank spaces.

Service units (7 positions, numeric)

Enter the total number of items/services for this service line.

For most services, the service units will be “1”. However, some services, such as physical therapy modalities or pints of blood, may be billed in multiples.

Total charges (7 positions for dollars; 2 positions for cents [numeric])

Enter the total charges pertaining to the related revenue codes for the current billing period. Total charges includes both covered and non-covered items.

Non-covered charges (7 positions for dollars; 2 positions for cents [numeric])

Enter the amount of non-covered charges if applicable.

Non-covered services include items such as patient convenience items or services specifically excluded by the patient's health plan.

Untitled

Reserved for assignment by NUBC

Payer [health plan] name (3 lines, 23 positions, alphanumeric)

Enter the name(s) of payer(s) in order of primacy. For example, if HMSA is the primary payer and Medicare is the secondary payer, list HMSA on Line A and Medicare on Line B. Line C may be used to identify a tertiary payer.

Notes:

1. For HMSA’s QUEST Integration plan enter the name HMSA QST Integration.

4. HMSA plan information should be consistently listed on the same line in form locators 50, 52, 54 and 57.

Health plan ID

Not applicable to HMSA at this time. This field is reserved for future use. The field will be used to report the National Health Plan Identifier when the final rule is implemented.

Notes:

1. Do not use this space for the member or provider ID number.
2. The member ID number should be entered in form locator 60.
3. The provider ID number should be entered in form locator 57.

Release of information certification indicator (3 lines, 1 position, alphanumeric)

Note: HMSA plan information should be consistently listed on the same line in form locators 50, 52, 54 and 57.

Assignment of benefits indicator (3 lines, 2 position, alphanumeric)

This field is not applicable to HMSA.

Note: HMSA does not accept assignment of benefits. HMSA makes payment only to members (when the provider is nonparticipating) and to participating providers.

Prior payments – payer

(3 lines -8 positions for dollars and 2 positions for cents [numeric]).

Required when the payer listed on the same line (A, B, or C) in form locator 50 has paid an amount toward this bill.

Notes:

1. Enter the amount of the payment.
2. Do not use this field to enter payments made by the patient.
3. Please ensure that any payment amount shown in this section is entered on the same line (A, B or C) as the payer identified in form locator 50.

Estimated amount due – payer

This field is not applicable to HMSA.

National Provider identifier (NPI) – billing provider (15 positions, numeric)

Optional

HMSA does not require the provider’s NPI on hard-copy claims.

Note: Even though this field length is 15 positions, the NPI is only 10 digits. If used, enter 10 digits only, and left-justify the number in the field.

Other (billing) provider identifier (3 lines, 15 positions, alphanumeric)

This field should be used for the appropriate HMSA provider ID number (legacy number).

Notes:

1. The legacy number must be used on hard-copy claims.
2. Enter the entire 10-digit, alphanumeric number
3. HMSA plan information should be consistently listed on the same line in form locators 50, 52, 54 and 57.
4. The provider number must be for the level of care and services billed.For example, use the acute provider number for acute services, use the SNF provider number if billing for SNF level bed, etc. Do not use an ancillary provider number to bill for room and board services.

Insured’s name (3 lines, 25 positions, alphanumeric)

Enter the name of the insured(s) on the line (A, B, or C) of this form locator corresponding to each health plan identified in form locator 50.

1. Last name should be entered exactly as shown on the membership card; e.g., VAN PLATT, HUGHES-CHING, MACDONALD.
2. Titles, such as Mr. or Dr., should not be recorded as data elements.
3. To add a suffix (e.g., Jr. or III.) to a name, write the last name, leave a space and write the suffix exactly as shown on the membership card. Then write the first name as in CARTER JR., DAVID W.

Insured’s unique identifier (3 lines, 20 positions, alphanumeric)

Required

Enter the unique member number on the line (A. B or C) corresponding to the insured(s) name identified in form locator 58.

Notes:

Enter only the 10-character member ID number (numeric) including any leading zeros. Do not enter prefix characters (e.g. XLQ).

Treatment authorization code (3 lines, 30 positions, alphanumeric)

Required only when specific drugs, devices or treatment require precertification under HMSA guidelines.

Notes:

1. Enter the HMSA precertification number on the line (A, B, or C) that corresponds to the HMSA membership number in form locator 60.
2. Do not enter precertification or treatment authorization numbers that are applicable to other health plans.

Document control number (3 lines, 26 positions, alphanumeric)

Required on replacement claims, resubmissions and void claims.

Notes:

1. Enter the Claim ID number (shown just beneath the patient’s name on the Report to Provider) on the line (A, B or C) that corresponds to the QUEST Integration membership number from Form Locator 60.
2. Required only for claims previously processed by HMSA QUEST Integration. Not applicable to claims processed by other health plans.

Diagnosis and procedures code qualifier (1 position, numeric)

Not required by HMSA.

Principal diagnosis code and present on admission (POA) indicator (8 positions total – 7 positions for the diagnosis code; 1 position for the POA indicator.Diagnosis code – alphanumeric; POA indicator – alpha)

The principal diagnosis code is required for both inpatient and outpatient claims. Use of the POA code indicator is optional.

Notes:

A decimal between the 3rd and 4th digit is implied and does not need to be entered.

Please left justify the ICD code.

If a POA indicator is used, space must be added between the diagnosis code and the indicator. The POA indicator should be right justified.

Definition: The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient for care.

Other diagnosis codes (8 positions total – 7 positions for the diagnosis code; 1 position for the POA indicator. Diagnosis code – alphanumeric; POA indication – alpha.)

Situational

Other diagnosis codes may be required in some situations and should be listed when appropriate. Use of the POA indicator is optional.

Notes:

A decimal between the 3rd and 4th digit is implied and does not need to be entered.

Please left justify the ICD code.

If a POA indicator is used, space must be added between the diagnosis code and the indicator. The POA indicator should be right justified.

Criteria:

1. Other diagnosis codes that may be listed in addition to the principal diagnosis include diagnosis codes for conditions that coexist at the time of admission, that develop subsequently or that affect the treatment received and/or length of stay.
2. Specifically, these would include conditions that affect patient care by requiring clinical evaluation, therapeutic treatment or diagnostic procedures, or which extend the length of the hospital stay or increase the nursing care and/or monitoring.
3. If a definitive diagnosis has been established and is listed, symptoms of that diagnosis should not be listed. For example, fever is a common symptom of pneumonia and should not be separately listed as a secondary diagnosis or complication when pneumonia is a listed diagnosis.

Admitting diagnosis (7 positions, alphanumeric)

Required only for the following types of bill: 011x, 012x, 018x and 021x.

Notes:

Only one admitting diagnosis may be reported.

A decimal between the 3rd and 4th digit is implied and does not need to be entered.

Please left justify the ICD code.

Definition: The admitting diagnosis is defined as a significant finding representing patient distress, an abnormal finding on examination, a possible diagnosis based on significant findings, a diagnosis established from a previous encounter or admission, an injury, a poisoning, or a reason or condition (not an illness or injury) such as follow-up or pregnancy in labor.

Patient reason for visit (3 lines, 7 positions, alphanumeric)

This field is intended for use with ER, urgent care and observation services to represent the diagnosis describing the patient's stated reason (or reason as stated by the patient's representative) for seeking care.

Notes:

A decimal between the 3rd and 4th digit is implied and does not need to be entered.

Please left justify the ICD code.

Prospective payment system (PPS) code (4 positions, numeric)

Not required by HMSA.

External cause of injury (ECI) code (3 fields, 8 positions per field – 7 positions for the diagnosis code; 1 position for the POA. Diagnosis code – alphanumeric; POA indicator – alpha).

An ECI diagnosis code is required when an injury, poisoning or adverse effect is the cause for the patient’s seeking treatment or occurs during the medical treatment. Use of the POA indicator is optional.

Notes:

A decimal between the 4th and 5th digit is implied and does not need to be entered.

The diagnosis code should be left justified.

If a POA indicator is used, space must be added between the diagnosis code and the indicter. The POA indicator should be right justified.

Multiple EDI diagnosis codes may be used as needed to fully explain the circumstances applicable to the case.

For HMSA, one of the codes used must be from the code range E849.0 - E849.9 describing the place of occurrence.

Untitled

Reserved for assignment by NUBC

Principal procedure code and date (1 field, 2 sections with a 7-position ICD code [alphanumeric] and a 6-position date [numeric])

Required on inpatient claims only when a procedure was performed. Also required on claims for lithotripsy and extracorporeal shockwave lithotripsy (ESWL) and electronconvulsive therapy (ECT).

Notes:

Please left justify the ICD code.

A decimal between the 2nd and 3rd digit is implied and does not need to be entered.

Enter the date the procedure occurred in MMDDYY format. Example, for March 5, 2007, enter the date as 030507.

1. Do not use slash marks.
2. Do not leave blank spaces.

Other procedure codes and dates (5 fields with 2 sections each, including a 7-position ICD code [alphanumeric] and a 6-position date [numeric])

Required on inpatient claims only when additional procedures must be reported.

Notes:

Please left justify the ICD code.

It is not necessary to indicate the decimal between the second and third digits of the ICD codes.

Enter the date the procedure(s) occurred in MMDDYY format. Example, for March 5, 2007, enter the date as 030507.

1. Do not use slash marks.
2. Do not leave blank spaces.

Untitled

Reserved for assignment by NUBC.

Attending provider name and identifiers(5 fields on 2 lines [alphanumeric]. Line 1, 11 positions + 2 positions + 9 positions.Line 2, 16 positions + 12 positions)

Definition: The attending provider is the individual who has overall responsibility for the patient's medical care and treatment.

Line 1.

NPI section. NPI is not required by HMSA on paper claims. Entering an NPI number in this section is optional. Although 11 positions are allowed, the NPI is a 10-digit number.

Secondary identifier qualifier. The HMSA legacy provider number is required in this section. There are 2 parts in this section. The first part holds 2 digits; the second part holds 9 digits. Because the HMSA provider number is 10 digits long, the two parts of this section must be combined to allow sufficient space to enter the HMSA provider number. Combining the two sections allows for a total of 11 digits.

Notes:

1. Enter the 10-digit provider number in the combined space starting with the first space on the left (left justified).
2. Enter the entire 10-digit number.
3. Do not delete leading zeros or the check digit to make the number fit into the 9-digit space.

Line 2

The attending physician’s name is required in this section. Enter the attending physician's name in last name, first name format.

Notes:

1. Capital letters are preferred.
2. A middle initial is not required but may be added if there is sufficient space following the first name.
3. Titles, such as MD., should not be entered.

Operating physician name and identifiers (5 fields on 2 lines [alphanumeric]. Line 1, 11 positions + 2 positions + 9 positions.Line 2, 16 positions + 12 positions)

Required when a surgical procedure code is listed on the claim.

Definition: The operating provider is the individual with the primary responsibility for performing the surgical procedure.

Line 1.

NPI section. NPI is not required by HMSA on paper claims. Entering an NPI number in this section is optional. Although 11 positions are allowed, the NPI is a 10-digit number.

Secondary identifier qualifier. The HMSA legacy provider number is required in this section if applicable. There are 2 parts in this section. The first part holds 2 digits; the second part holds 9 digits. Because the HMSA provider number is 10 digits long, the two parts of this section must be combined to allow sufficient space to enter the HMSA provider number. Combining the two sections allows for a total of 11 digits.

Notes:

1. Enter the 10-digit provider number in the combined space starting with the first space on the left (left justified).
2. Enter the entire 10-digit number.
3. Do not delete leading zeros or the check digit to make the number fit into the 9-digit space.

Line 2

The operating physician’s name is required in this section if applicable. Enter the operating physician’s name in last name, first name format.

Notes:

1. Capital letters are preferred.
2. A middle initial is not required but may be added if there is sufficient space following the first name.
3. Titles, such as MD., should not be entered.

Other provider [individual] names and identifiers (5 fields on 2 lines [alphanumeric]. Line 1, 11 positions + 2 positions + 9 positions.Line 2, 16 positions + 12 positions)

Definition: Other providers might include assistant surgeon, consulting physician, referring physician, etc.

Line 1.

Provider Type Qualifier Codes. A valid provider type qualifier is required.

DN – Referring Provider

ZZ – Other Operating Physician

82 – Rendering Provider

NPI section. NPI is not required by HMSA on paper claims. Entering an NPI number in this section is optional. Although 11 positions are allowed, the NPI is a 10-digit number.

Secondary identifier qualifier. The HMSA legacy provider number is required (if known) in this section. There are 2 parts in this section. The first part holds 2 digits; the second part holds 9 digits. Because the HMSA provider number is 10 digits long, the two parts of this section must be combined to allow sufficient space to enter the HMSA provider number. Combining the two sections allows for a total of 11 digits.

Notes:

1. Enter the 10-digit provider number in the combined space starting with the first space on the left (left justified).
2. Enter the entire 10-digit number.
3. Do not delete leading zeros or the check digit to make the number fit into the 9-digit space.

Line 2

Enter the other physician’s name in last name, first name format.

Notes:

1. Capital letters are preferred.
2. A middle initial is not required but may be added if there is sufficient space following the first name.
3. Titles, such as MD., should not be entered.

Other provider [individual] names and identifiers (5 fields on 2 lines [alphanumeric]. Line 1, 11 positions + 2 positions + 9 positions.Line 2, 16 positions + 12 positions)

Definition: Other providers might include assistant surgeon, consulting physician, referring physician, etc.

Line 1.

Provider Type Qualifier Codes. A valid provider type qualifier is required.

DN – Referring Provider

ZZ – Other Operating Physician

82 – Rendering Provider

NPI section. NPI is not required by HMSA on paper claims. Entering an NPI number in this section is optional. Although 11 positions are allowed, the NPI is a 10-digit number.

Secondary identifier qualifier. The HMSA legacy provider number is required (if known) in this section. There are 2 parts in this section. The first part holds 2 digits; the second part holds 9 digits. Because the HMSA provider number is 10 digits long, the two parts of this section must be combined to allow sufficient space to enter the HMSA provider number. Combining the two sections allows for a total of 11 digits.

Notes:

1. Enter the 10-digit provider number in the combined space starting with the first space on the left (left justified).
2. Enter the entire 10-digit number.
3. Do not delete leading zeros or the check digit to make the number fit into the 9-digit space.

Line 2

Enter the other physician’s name in last name, first name format.

Notes:

1. Capital letters are preferred.
2. A middle initial is not required but may be added if there is sufficient space following the first name.
3. Titles, such as MD., should not be entered.

Remarks Field (4 lines, free-form alphanumeric text. Line 1 – has 19 positions; lines 2-4 have 24 positions.)

Required when in the judgment of the provider the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.

For claim resubmission or void claims, include text explaining reason for correction when Condition Code = “D9” (any other change).

Code-code field

This field is specifically designated as an overflow field that can be used to supply additional condition codes, occurrence codes/dates, occurrence span codes/dates or value codes/amounts.

Directions for completing overflow fields are consistent with the directions described in the specific code field locators for the code(s) in question. Additional information can be found in the NUBC Official Data Specifications Manual.

Note: CMS has suggested the use of this field for taxonomy codes. HMSA does not currently plan to use this field for the taxonomy code.