N.H. Admin. Code § He-C 1503.04

Current through Register No. 50, December 12, 2024

Section He-C 1503.04 - Required Data Elements

(a) The following elements from the UB-04 reporting standard shall be submitted as follows:

(1) UB-04 Form Locator 01, "billing provider name, address and telephone number";

(2) UB-04 Form Locator 02, "pay-to name and address";

(3) UB-04 Form Locator 03a, "patient control number";

(4) UB-04 Form Locator 03b, "medical/health record number", which shall be required on all claims;

(5) UB-04 Form Locator 04, "type of bill";

(6) UB-04 Form Locator 05, "federal tax ID number";

(7) UB-04 Form Locator 06, "statement covers period";

(8) UB-04 Form Locator 08, "patient name/identifier", which shall:

a. Be encrypted using a standard methodology and software provided by the department or its agent before submission to the department or its agent; and

b. Be divided into 4 distinct components of patient last name, patient first name, patient middle name, and patient generational identifier suffix, all provided in upper case prior to encryption;

(9) UB-04 Form Locator 09, "patient address";

(10) UB-04 Form Locator 10, "patient birth date";

(11) UB-04 Form Locator 11, "patient sex";

(12) UB-04 Form Locator 12, "admission/start of care date", which shall be required on all claims;

(13) UB-04 Form Locator 13, "admission hour", which shall be required on all claims;

(14) UB-04 Form Locator 14, "priority (type) of visit";

(15) UB-04 Form Locator 15, "point of origin for admission or visit";

(16) UB-04 Form Locator 16, "discharge hour", which shall be required on all inpatient and observation stay claims;

(17) UB-04 Form Locator 17, "patient discharge status";

(18) UB-04 Form Locator 18 through 28, "condition codes", which shall:

a. Be submitted as recorded; and

b. Be collected, recorded, and submitted where applicable for:

1. 02 = Condition is Employment-Related; and

2. P1 = Do Not Resuscitate Order (DNR);

(19) UB-04 Form Locator 31 through 34, "occurrence codes and dates 1 - 4", which shall:

a. Be submitted as recorded; and

b. Be collected, recorded, and submitted where applicable for 04 = Accident/employment related date;

(20) UB-04 Form Locator 39 through 41, "value codes and amounts", which shall:

a. Be submitted as recorded; and

b. Be collected, recorded, and submitted where applicable for:

1. 54 = Newborn Birth Weight in Grams; and

2. P0 = For newborns, mother's medical record number;

(21) UB-04 Form Locator 42, "revenue code";

(22) UB-04 Form Locator 44, "HCPCS or CPT/accommodation rates/HIPPS rate codes", except the length limit shall not apply;

(23) UB-04 Form Locator 45, "service date";

(24) UB-04 Form Locator 46, "service units";

(25) UB-04 Form Locator 47, "total charges";

(26) UB-04 Form Locator 50, "payer name", except the length limit shall not apply;

(27) UB-04 Form Locator 51, "health plan identification number";

(28) UB-04 Form Locator 56, "national provider identifier - billing provider";

(29) UB-04 Form Locator 57, "other (billing) provider identifier";

(30) UB-04 Form Locator 59, "patient's relationship to insured";

(31) UB-04 Form Locator 64, "document control number";

(32) UB-04 Form Locator 65, "employer", which shall:

a. When the employer is not known, be recorded as "UNKNOWN"; and

b. When not employed, be recorded as "NA.";

(33) UB-04 Form Locator 66, "diagnosis and procedure code qualifier";

(34) UB-04 Form Locator 67, "principal diagnosis code and present on admission indicator" which for the present on admission (POA) element shall only be recorded on inpatient acute care discharges;

(35) UB-04 Form Locator 67A-Q, "other diagnosis codes and present on admission indicator" which for the POA element shall only be recorded on inpatient acute care discharges;

(36) UB-04 Form Locator 69, "admitting diagnosis code";

(37) UB-04 Form Locator 70A-C, "patient's reason for visit";

(38) UB-04 Form Locator 72A-C, "external cause of injury code (ECI) and present on admission indicator", which shall be reported in order for every applicable principal and other diagnoses;

(39) UB-04 Form Locator 74, "principal procedure code and date";

(40) UB-04 Form Locator 74A-E, "other procedure codes and dates";

(41) UB-04 Form Locator 76, "attending provider name and identifiers";

(42) UB-04 Form Locator 77, "operating physician name and identifiers";

(43) UB-04 Form Locator 78 and 79, "other provider (individual) names and identifiers";

(44) UB-04 Form Locator 80, "remarks"; and

(45) UB-04 Form Locator 81A-D, "code-code field", which shall:

a. Be submitted as recorded; and

b. Be collected, recorded, and submitted where applicable for B1 (race and ethnicity) .

(b) The health care facility shall submit information regarding primary language spoken as an integer numeric element which health care facilities shall code consistently.

N.H. Admin. Code § He-C 1503.04

# 9436, eff 3-21-09

Amended by Volume XXXVII Number 15, Filed April 13, 2017, Proposed by #12139, Effective 3/22/2017, Expires 9/18/2017.