The section of the UB-04 claim form that contains FLs 50-65 is used to report details about the payer, the insured, and the insured's employer. Payer, insured, and employer information are required on the UB-04 to make an accurate determination of benefits as well as to coordinate benefits when there is more than one payer.
FLs 50-55 and FL 57 on the UB-04 contain details about the payer. Each of these fields has three lines, labeled A, B, and C, used to identify the primary, secondary, and tertiary payer, respectively.
FL 50 contains the name for each payer.
FL 51 contains the health plan ID for each payer.
FL 52 indicates whether the provider has a release of information authorization from the patient.
FL 53 indicates whether the patient has assigned the benefits directly to the provider.
FL 54 is used to report any payment of the bill received to date from the payer(s) listed in FL 50.
FL 55 is used to estimate the amount due from the payer(s) listed in FL 50 (the estimated responsibility less any payments received).
FL 57 is used to report the health plan legacy number assigned to the provider by the indicated payer in FL 50; it is used as a secondary identifier to supplement the NPI when required.
FL 56 in this section, which contains only one line, indicates the billing provider's ten-digit National Provider Identifier (NPI), mandated by HIPAA for use as the provider's primary identifier beginning May 23, 2007. The NPI is a unique identifier assigned to each provider nationally for lifetime use. The NPI Registry is a query-only database available through the CMS website that contains a complete listing of NPIs and other provider data that are available to the public.
Situations in which Medicare may be listed as a secondary payer (FL 50, line B) on a claim include the following:
Another payer paid some of the charges, and Medicare is secondarily liable for the remainder.
Another payer denied the claim.
The provider is requesting a conditional payment.
When Medicare is billed as a secondary payer, the applicable value code and amount received from the primary insurer must be reported in FLs 39-41 (Value Codes and Amounts) on the UB-04.
The insured portion of the UB-04 claim includes FLs 58-62. FL 58 (Insured's Name) contains the name of the patient or the individual in whose name the insurance listed in FL 50 is issued. This name must correspond with the name on the insured's identification card. The remaining FLs in this portion all pertain to the person identified in FL 58.
FL 59 indicates the patient's relationship to the insured.
FL 60 contains the insured's identification number assigned by the payer organization.
FL 61 indicates the name of the group or plan that is providing coverage to the insured.
FL 62 indicates the insurance group number under which the insured individual is being covered.
The last portion of the payer, insured, and employer information section of the UB-04 contains FLs 63-65.
FL 63 is used to report a treatment authorization code when an authorization or referral number is assigned by the payer or utilization management organization (UMO), or in the case of Medicare by the Quality Improvement Organization (QIO).
FL 64 is used to report the document control number (DCN), also known as the internal control number (ICN), assigned to the original bill by the indicated health plan in FL 50; it is reported on the UB-04 only when filing a replacement or cancellation to a previously processed claim (TOB 0XX7 or 0XX8).
FL 65 contains the name of the employer who is providing health care coverage for the insured indicated in FL 58 (for use with paper claims only).
