Institutional Claims – UB04

These features are only available if the ‘Institutional Claims’ Add-On is activated

See Institutional Claims Add-On for more information on activating.

Quick checklist for Institutional claim submitters:

1.   Enter Institutional Activation Code in Libraries>Add-On Services.  Code is provided by EZClaim.

2.   Update Claim Type in Payer Library to ‘Institutional’ for applicable payer(s) only. Payer IDs may be different for Institutional vs Professional claims sent to the same payer.  Please verify payer IDs with your clearinghouse as needed.

3.   Set up Submitter/Receiver Library Institutional Entry using the 837I export format (screenshot below).

4.   Activate ‘Institutional’ section of Claim grid (screenshot below).

5.   Add ‘Revenue Code’ and ‘To Date’ on Service Line grid (screenshot below).

Important:  Institutional grid layouts are user specific. 

 

Payer Library

IMPORTANT:

Payer library setup is required before billing institutional claims.  If you are registered with a payer as an institutional organization, select ‘Institutional’ as the Claim Type.  This is how the program knows which claim form to print or which claims are available to export electronically.  You may need two separate Payer Library entries if you will continue sending Professional claims as well. 

Data Entry

Once the Add-On is enabled, additional custom columns are available on the claim screen.  Add additional columns as needed to both the service line grid and the claim grid.  For more information on customizing grids, see Grids.

Adding additional columns to the Service Line grid:

The service line grid is normally sorted by Srvc Date.  For Institutional claims, the Revenue Code should be included in the sort.  To change the grid sort, click the Revenue Code column header to sort, hold the shift key down, and then click the Srvc Date field to add it to the sort order.  The column headings will show triangles to indicate they are both included in the sort.

Adding the Institutional Group to the Claim grid:

Adding additional columns to the Claim grid:

Submitter/Receiver Library

A new format is available in the Submitter/Receiver library.  IMPORTANT: You must setup a library entry with the ANSI 837 Institutional Export Format to send claims in the 837I format.

The send claims screen will show professional or institutional claims depending on the Submitter/Receiver library selected.

Print Setup

A new Program Setup options section is available for institutional claims.  Click Tools > Program Setup then select Printing Institutional Claims to manage the options.

Printing Claims

When opening the print claims window, a new filter option is available allowing you to print the institutional claim.  The list will filter based on the type of claim.

ANSI 837 Institutional

SV2 02-1: This field (procedure code qualifier) is typically ‘HC’.  A qualifier of ‘HP’ will be used if the procedure code matches the following characteristics: First character is ‘1’ through ‘5’, second character is ‘A’ through ‘E’ and third character is ‘F’ through ‘J’.

UB-04 Boxes (Form Locator)

Many of the fields for the UB-04 form need to be added manually to the grids.  See Grids for information on adding additional columns.

Field No.

Field Name

Screen > Field

Notes

1

Provider Name and Address

Claim > Billing Provider

 

2

Service Facility

Claim > Service Facility

 

3a

Pat. Cntl #

Claim > Claim ID (or Invoice #)

Will use the Invoice # if available otherwise, the Claim ID.

3b

Med Rec #

Patient > Account #

 

4

Type of Bill

Claim > Type of Bill

 

5

Fed. Tax No.

Claim > Billing Provider

Billing Provider Tax ID number as entered into Phy library.

6

Statement Covers Period

 

Min and Max of date of services (earliest From date and the last To date) OR the values contained in the ‘Statement From Override’ and ‘Statement Through Override’ columns available as custom columns on the claim Grid.

7

 

 

Not Available

8a

Patient’s Member ID

Patient > Member ID

 

8b

Patient Name

Patient > Name

Patient Last First MI (no extra punctuation)

9a

Patient’s Address

Patient > Address

Patient’s address (not insured’s)

9b

Patient’s City

Patient > City

 

9c

Patient’s State

Patient > State

 

9d

Patient’s Zip

Patient > Zip

 

9e

 

 

Not Available

10

Date of Birth

Patient > DOB

 

11

Sex

Patient > Sex

M, F, or U for Unknown

12

Admission Date

Claim > Admitted Date

 

13

Admission Hour

Claim > Admission Hour

 

14

Admission Type

Claim > Admission Type

 

Field No.

Field Name

Screen > Field

Notes

15

Admission Source

Claim > Admission Source

 

16

Discharge Hour (DHR)

Claim > Discharge Hour

 

17

Patient Status (STAT)

Claim > Patient Status

 

18-21

Condition Codes

Claim Condition Code 1-4

Only 4 codes available

22-28

Condition Codes

 

Not Available

29

Acdt State

Claim > Auto Accident State

 

30

 

 

Not Available

31a thru 34a

Occurrence Code

Occurrence Date

Claim > Occurrence Code 1-4

Claim > Occurrence Date 1-4

 

31b thru 34b

Occurrence Code

Occurrence Date

Claim > Occurrence Code 5-8

Claim > Occurrence Date 5-8

 

35a

Occurrence Span Code

Claim > Occurrence Span Code 1

Only 1 span available

35a

Occurrence Span From-Through

Claim > Occurrence Span From 1

Claim > Occurrence Span To 1

Only 1 span available

35b and 36a-b

Occurrence Span Code

Occurrence Span From and Through Date

 

Not Available

38

Responsible Party Name and Address (Claim Addressee)

Claim > Bill To

Print the Bill To name and address.  If the Bill To is ‘Patient’ then the patient’s address will print in this box.

39a-41a

Value Codes

Amounts

Claim > Value Code 1-12

Claim > Value Code Amount 1-12

12 value codes/amounts available

39b-41d

Value Codes and Amounts

 

Not Available

42

Revenue Code

Claim > Revenue Code

Available on each service line.  Will print blank if left blank.  The Total charges line will automatically contain 0001.

43

Description

Claim > Service Line Description

Prints the service line description.  Will print blank if left blank.  No lookup is performed.

44

HCPCS/RATE/HIPPS CODE

Claim > Procedure

Will print procedure code with up to 4 modifiers.  All separated by a space.

45

Service Date

Claim > Srvc Date

Lines sorted by revenue code then DOS

46

Service Units

Claim > Units

 

Field No.

Field Name

Screen > Field

Notes

47

Total Charges

Claim > Charges

Will only be printed on the last page

48

Non Covered Charges

Claim > Non-Covered Charges

Available in release 560 and higher

Line 23

Creation Date

Claim > Original Bill Date

 

Line 23

Total Charges

 

Calculated by the program.  Total of all Charges

Line 23

Total Non-Covered Charges

 

Non-Available

49

 

 

Not Available

50 A, B,C

Payer Name

Claim > Bill To

Up to 3 payers listed

A – Primary

B – Secondary

C – Tertiary

51 A, B, C

Health Plan ID

Claim > Bill To

The ‘Payer ID’ from the payer library

A – Primary

B – Secondary

C – Tertiary

52

Release of Information

Patient > Patient Signature on File

Will print ‘Y’ if the Patient Signature on File is checked.  Otherwise blank.

53

Assignment of Benefits

Patient > Insured Signature on File

Will print ‘Y’ if the Insured Signature on File is checked.  Otherwise blank.

54 A,B,C

Prior Payments

 

Will show as long as the claim’s “Ignore Applied Amount” is not checked

55 A,B,C

Est Amt Due from Payer

 

Not Available

56

NPI

Claim > Billing Provider

Provider NPI from the physician library

57

Other Provider ID

Claim > Billing Provider

Provider additional ID number (specific to payer).  No qualifier is printed.

58

Insured’s Name

Claim > Bill To > Name

Insured information

59

P. Rel

Claim > Bill To > Patient Rel to Insured

Insured information

60

Insured’s Unique ID

Claim > Bill To > Insured’s ID #

Insured

61

Group Name

Claim > Bill To > Insured’s ID #

 

62

Insurance Group No

Claim > Bill To > Group #

 

63

Treatment Authorization Codes

Claim > Prior Auth #

 

64

Document Control Number

Claim > Original Ref Number

Original Ref Number from the claim screen.  Will print in line A for primary claim, line B for secondary claim, and line C for Tertiary claim.

66

Diagnosis and Procedure Code Qualifier (ICD Version Indicator)

Claim > ICD Indictor

9 for ICD-9 or 0 for ICD-10

67

DX: principal diagnosis code

Claim Diagnosis A1

Diag A1

67 A-Q

Other diagnosis codes and Present On Admission (POA) indicator

Claim Diagnosis B2-L12

Diag B2-L12

Field No.

Field Name

Screen > Field

Notes

69

ADMIT DX

Claim > Admitting Diagnosis

 

70 a, b, c

Patient Reason DX

Claim > Patient Reason 1,2,3

 

71

PPS

Claim > PPS Code

 

72

External Cause Code - ECI

 

Not available

73

 

 

Not Available

74

Principal Procedure Code and Date

Claim > Principal Procedure Code and Date

 

74a-e

Other Procedure Code and Date

Claim > Other Procedure Code and Date

 

75

 

 

Not Available

76 (NPI)

Attending Physician NPI

Claim > Attending

Provider NPI from the physician library

76 (QUAL and ID)

Attending Additional ID Numbers

Claim > Attending

Provider additional ID number from the physician library

76 (LAST and FIRST)

Attending Physician Last and First Name

Claim > Attending

 

77

Operating Phy

Claim > Operating Provider

 

78-79

Referring Phy and/or Rendering Phy

Claim > Referring Provider and/or Rendering Provider

Will populate box 78 if only one provider is selected or 78 and 79 if two providers are selected.  Rendering providers will have a qualifier of 82 and referring providers will have a qualifier of DN.

 

The rendering and referring provider will not print if their NPI is the same as the Attending.

80

Remarks

Claim > Remarks

 

81CC a

Code-Code Field

Claim > Billing Provider

Prints the billing provider’s Taxonomy code.  The prefix is B3 and the code is printed in the second column

 

Special Note on the POA indicator:  The POA (Present on Admission) Indicator is a 25 character text value for potentially assigning POA indicators to each of the 25 diagnosis codes. the first character in the string will be the POA indicator for the first diagnosis, the second character, for the second diagnosis and so on. Because the program doesn't tend to preserve leading or trailing spaces, if the user wanted to NOT assign any POA indicator first the first diag, but assign one to the second, a special character (we picked *) is required to represent the blank.  A value of "*Y" would result in a POA of Y in the second diag with nothing for the first.