New UB04 Claim Form changes to INTELEC

The National Uniform Billing Committee (NUBC) approved the UB04 claim form as a replacement for the UB92 form at a meeting in February 2005. As a result of this decision it is stated that it is mandatory that all institutional paper claims must use UB04 form starting from May 23^rd 2007.

It is not clear as to whether there will be any extensions of the required starting date for the new forms or if some companies may still require the old form. For this reason, we have kept both formats. We have also given you a conversion program for the UB92 to UB04 data mapping.

From the “Insurance Information screen” (F16), you can access the new UB04 form by pressing F9. This is indicated on the bottom left part of the screen (F3/9–UB). Pressing F3 will take you to the UB92 screen.

From the first UB04 screen (F9 from Insurance screen), you can navigate to the 2^nd screen by using F2. The 3^rd UB04 screen can be accessed by using F12 which will update and display the next screen. You can use update (F12) from the last screen to update all the UB04 information.

The INTELEC changes with regard to UB04 from that of UB92 are as follows:

• In the Insurance Information Screen, *UB04 in yellow indicates that you have UB04 information. *UB92 will mean you have UB92 information. If you have data in both UB92 and UB04 it will show as *UBXX.

• Covered Days (FL07), Non–Covered Days (FL08), Coinsurance Days (FL09) and Lifetime Reserve Days (FL10) which were in UB92, were removed in the UB04 Form.

• Patient Name field (FL12 in UB92) has been split to include Patient ID (FL8a) and Patient Name (FL8b) in the the UB04.

• Patient Address filed is split into 5 cells in UB04. They are as follows;

• Patient Address – Street (FL9a)
• Patient Address – City (FL9b)
• Patient Address – State (FL9c)
• Patient Address – Zip (FL9d)
• Patient Address – Country Code (FL9e)

• Patient Marital Status field (FL16 in UB92) has been removed in UB04.

• Four new spaces for condition codes have been added.

• A new field called ACDT STATE (Accident State) has been added. (FL29)

• In the UB92 there was only one "Occurrence Span Code/From/Through" field (FL36 in UB92) but in the UB04, there are two "Occurrence Span Code/From/Through" fields (FL 35 and 36).

• New fields "Page_____of_____" (Lower part of FL43 column) and "Creation Date" (Lower part of FL44 column) have been added.

• The field lengths of "Total Charge" (FL47) and "Non-covered Charges” (FL48) fields have been reduced by 1 digit.

• Provider No. (FL51 in UB92) has been renamed as "Health Plan ID" in the UB04 screen.

• New fields for "NPI" (National Provider ID) and "Other Provider ID" have been added. (FL 56 and57)

• The "Cert/SSN/HIC/ID No." field in the UB92 has been renamed as "Insured's Unique ID" in the UB04 (FL60).

• The ESC (Employment Status Code) in UB92 (FL64) has been removed in the UB04 screen.

• The Internal Control No. has been renamed as Document Control No. in the UB04. (FL64)

• Employer Location field (FL66 in UB92) has been removed.

• A new field called "DX' (Diagnosis/Procedure Code Qualifier) had been added. (FL66)

• Nine new spaces have been added for Principal Diagnosis Code/Other Diagnosis Codes. (FL67)

• ADMIT DX (Admitting Diagnosis Code) field size has been expanded by 1 digit. (FL69)

• A new field called "Patient Reason DX" (FL70) has been added with three spaces to add patient reason DX codes.

• A new field for PPS Code (Prospective Payment System Code) has been added. (FL 71)

• Two new spaces have been added for E-code (External Cause of Injury) in UB04 screen. (FL72)

• Field sizes of "Principal Procedure code/Date" and "Other procedure code/Date" fields have been expanded by 1 digit. (FL74 a-e)

• The P.C. (Procedure code method used) field has been removed in the UB04. (FL79 in UB92)

•  There is provision for placing the Attending Physician's NPI/QUAL/ID and their name on the 3^rd screen of the UB04 form in INTELEC. (FL76)

• New fields for "Operating Physician NPI/QUAL/ID" and their name have been added. (FL77)

• New fields added for "Other Physician NPI/QUAL/ID" and their name. (FL78 and 79)

•  There is provision for adding the new field called "Code-code Field/Qualifiers". These are placed under the "Qual, Code, Value" headings on the 3^rd UB04 screen. (FL81)

• The field size of the remarks fields has cut down by half. (FL80) 

The Screen Prints of the three UB04 Screens in INTELEC are as follows:-

1^st Screen

2^nd Screen

3^rd Screen

Printing data to UB04 form as a test

To print a UB04 form you have to type "P" in the "Rebill" option as with the UB92.

Then Press F12 to update. After that you have to execute the following program from your command line.

CALL PRTINSU4CL

The above program will produce the UB04 form. We have created this for the laser printers only.

Converting Data from UB92 to UB04

When you go live with the UB04 you will want to convert the existing data from the UB92 to UB04 the format. We have a special program to convert data from UB92 to UB04 format. You have to submit this program from your command line as follows.

SBMJOB CMD (CALL ZCNVUVCL)

Instructions to follow when you go live

When you go live with the UB04, you should let us know. We will then send the "Nightly UB04 form printing" program and the "Electronic New Business Posting program". After going live, the New Business Posting program will load to the UB04 screens instead of the UB92 data.