Paper UB-04 Section - PM

Set the Paper UB-04 billing file default values.

1. In the Horizontal Offset field, type a positive or negative value for shifting the printed form right or left. Example: A positive one (1) shifts the print to the right one character space. A negative one (-1) shifts the print to the left.

2. In the Address Information To Print In Form Locator 1 field, select Provider Data From 'Facility Defaults' to use the information from the Facility Defaults form. Select Program Extended Dictionary to use the address information based on the program the service was posted under.

3. In the Form Locator 2 Pay-To Provider Name field, type the override value for form locator 2 (Pay To Provider Name).

4. In the Form Locator 2 Pay-To Street Address field, type the override value for form locator 2 (Pay-To Street Address).

5. In the Form Locator 2 Pay-To ZIP Code field, type the override value to include in form locator 2 (Pay-To ZIP Code).

6. In the Form Locator 2 Pay-To City field, type the override value to include in form locator 2 (Pay-To City).

7. In the Form Locator 2 Pay-To State field, select the override value to include in form locator 2 (Pay-To State).

8. In the Display For Form Locator 3 (Patient Account No.) field, select the display format for the client's account number.

9. In the Specify A Prefix Value... field, enter the prefix for form locator 3 (Patient Account Number).

10. In the Form Locator 4 (First Three Digits) field, select the override value to display in the first three digits of form locator 4.

11. In the Override To Type Of Bill For Medicare Certified Bed Stay (Form Locator 4) field, select the type of bill to override to for Medicare certified bed stays in form locator 4.

12. In the Override To Type Of Bill For Medicaid Certified Bed Stay (Form Locator 4) field, select the type of bill to override to for Medicaid certified bed stays in form locator 4.

13. In the If Patient Identifier (Form Locator 8a) Matches Insured's Unique ID (Form Locator 60) Suppress Patient Identifier field, select Yes to suppress the patient identifier if it matches the insured's ID. Select No not to suppress the patient identifier.

14. In the Information To Display For Form Locators 8b, 9, 10, And 11 field:

• Select Client's Information To Display For Form LocatDemographic Data to use the client's information in these form locators.

• Select Subscriber's Demographic Data in Financial Eligibility to use the subscriber's information in these form locators.

15. In the Form Locator 13 - Admission Hour field, select if Form Locator 13 is populated with "00" or "24" for clients whose time of admission is midnight.

16. In the Display For Form Locator 38 field, choose whether to display the Subscriber or Guarantor information in form locator 38.

17. In the Form Locator 42 - Number Of Digits For Revenue Code field, select the number of digits for the revenue code in form locator 42.

18. In the Form Locator 43 - Revenue Code Description field, choose which description to apply for the revenue code.

19. In the Form Locator 44 - Display HCPCS For The Following Revenue Code(s) field, select the ancillary revenue codes for inclusion of HCPCS information.

20. In the Include HCPCS Code For Room And Board Charges? field:

• Select Yes to allow the system to print the HCPCS code in Form Locator 44 for the Room and Board revenue codes selected in the Form Locator 44 - Display HCPCS For The Following Revenue Code(s) field.

• Select No to allows the system to print the revenue rate in Form Locator 44 for Room and Board revenue codes. This is the default setting.

21. In the Form Locator 45 - Display Dates Of Service For The Following Revenue Code(s) field, select the ancillary revenue codes for inclusion in dates of service information.
22. In the Form Locator 47 - Charge Calculation field, select how charges are calculated in form locator 47.
23. In the Form Locator 51 (Health Plan ID) field, type the override value for form locator 51 (Health Plan ID).
24. In the If Prior Payments (Form Locator 54) Equals Zero Suppress Prior Payments field, select Yes to suppress prior payments if form locator 54 equals zero. Select No not to suppress prior payments.
25. In the Form Locator 56 (National Provider Identifier) field, type the override value for form locator 56 (National Provider Identifier).
26. In the Form Locator 57 (Other Billing Provider ID) field, type the override value for form locator 57 (Other Billing Provider Number).
27. In the Form Locator 66 (ICD Version Indicator) field, designate the ICD version number.
28. In the Display Present On Admission Indicator Code For Form Locators 67 And 72 field, select Yes to display the Present On Admission Indicator Code For Form Locators 67 And 72. Otherwise, select No.
29. In the Exclude Punctuation From Claim - Form Locators 67-70, 72 And 74 field, select Yes to exclude punctuation in these form locators; select No to disable this function.
30. In the Select Type Of Information To Include In Form Locator 78 field, choose whether to include the Referring Practitioner or the Referring Provider in form locator 78, or if it should be left blank.
31. In the Display For Form Locator 80 field, select the information to display in form locator 80.
32. In the Form Locator 81-A-1 field, select the override value for form locator 81-A-1.
33. In the Form Locator 81-A-2 field, type the override value for form locator 81-A-2.
34. In the Form Locator 81-A-3 field, enter the override value to use in form locator 81-A-3.
35. In the Print As An Outpatient Bill If There Are No Room And Board Charges field, select Yes to print the UB-04 bill as an outpatient bill if it contains no room and board charges; select No to disable this function.
36. In the Sort Paper UB-04 Claims By field, select the manner in which to sort the Paper UB-04 claims (e.g., by the service date).
37. In the Include Zero Charge Services field, select whether or not zero charge services should be included on the claims.

• 837I-Dates To Populate 2300 DTP
• 837I Loops/Segments To Suppress
• Add Override For Billing Provider Name
• Add Override For Federal Tax Number
• Determine Non-Covered Charge Amount (Form Locator 48) From Fee Table
• Enable Modification Of Statement From Date
• Enable UB-04 Revenue Code Field For No-Pay ##0 Claims
• Enable DRG Codes For Non-PPS Bills
• Exclude Adjustments From Prior Payments Form Locator 54
• Fields to Include in Client Charge Input
• Form Locator Modifications
• Include CPT-4 Modifier If Not First Instance For Service Date
• Include First Billing Date
• Include POA Indicator
• Service Panel Charge Input - Fields To Include
• Specify Attending Provider At Guarantor/Program Level
• Specify Default Discharge Hour (Form Locator 16)
• Specify Occurrence Span Through Date As Last Date On Leave
• Specify Patient Status (Form Locator 17)
• Specify Payer Name Location (Form Locator 50)
• Suppress Covered/Non-Covered Days
• Suppress Estimated Amount Due Payer (Form Locator 55)
• Suppress Non-Billable Leaves
• Suppress Patient Id (Form Locator 8a)
• Suppress Prior Payments (Form Locator 54) For Zero Amount
• UB04 Suppressions
• Use Claim First/Last Dates Of Service
• Use Coverage Effective/Expiration Dates
• Use Zero Dollar Charge For Non-Billable Leaves