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6.4.10 UB1 - UB82 data segment

The UB1 segment contains the data necessary to complete UB82 bills. Only UB82 fields that do not exist in other HL7 defined segments appear in this segment. Patient Name and Date of Birth are required for UB82 billing; however, they are included in the PID segment and therefore do not appear here.

Figure 6-10. UB1 attributes

SEQ

LEN

DT

OPT

RP/#

TBL#

ITEM#

ELEMENT NAME

1

4

SI

O



00530

Set ID - UB1

2

1

NM

B



00531

Blood Deductible (43)

3

2

NM

O



00532

Blood Furnished-Pints Of (40)

4

2

NM

O



00533

Blood Replaced-Pints (41)

5

2

NM

O



00534

Blood Not Replaced-Pints(42)

6

2

NM

O



00535

Co-Insurance Days (25)

7

14

IS

O

Y/5

0043

00536

Condition Code (35-39)

8

3

NM

O



00537

Covered Days - (23)

9

3

NM

O



00538

Non Covered Days - (24)

10

12

CM

O

Y/8

0153

00539

Value Amount & Code (46-49)

11

2

NM

O



00540

Number Of Grace Days (90)

12

60

CE

O



00541

Spec Program Indicator (44)

13

60

CE

O



00542

PSRO/UR Approval Indicator (87)

14

8

DT

O



00543

PSRO/UR Approved Stay-Fm (88)

15

8

DT

O



00544

PSRO/UR Approved Stay-To (89)

16

20

CM

O

Y/5


00545

Occurrence (28-32)

17

60

CE

O



00546

Occurrence Span (33)

18

8

DT

O



00547

Occur Span Start Date(33)

19

8

DT

O



00548

Occur Span End Date (33)

20

30

ST

O



00549

UB-82 Locator 2

21

7

ST

O



00550

UB-82 Locator 9

22

8

ST

O



00551

UB-82 Locator 27

23

17

ST

O



00552

UB-82 Locator 45

6.4.10.0 UB1 field definitions

6.4.10.1 Set ID - UB1 (SI) 00530

Definition: This field contains the number that identifies this transaction. For the first occurrence of the segment the sequence number shall be 1, for the second occurrence it shall be 2, etc.

6.4.10.2 Blood deductible (NM) 00531

Definition: This field has been retained for backward compatibility only. Use IN2-21-blood deductible instead of this field, as the blood deductible can be associated with the specific insurance plan via that segment. This field is defined by HCFA or other regulatory agencies.

6.4.10.3 Blood furnished-pints of (40) (NM) 00532

Definition: This field contains the amount of blood furnished to the patient for this visit. The (40) indicates the corresponding UB82 field number. This field is defined by HCFA or other regulatory agencies.

6.4.10.4 Blood replaced-pints (41) (NM) 00533

Definition: This field contains UB82 Field 41. This field is defined by HCFA or other regulatory agencies.

6.4.10.5 Blood not replaced- pints (42) (NM) 00534

Definition: This field contains the blood not replaced, as measured in pints. UB82 Field 42. This field is defined by HCFA or other regulatory agencies.

6.4.10.6 Co-insurance days (25) (NM) 00535

Definition: This field contains UB82 Field 25. This field is defined by HCFA or other regulatory agencies.

6.4.10.7 Condition code (IS) 00536

Definition: The code in this field repeats five times. UB82 Fields (35), (36), (37), (38), and (39). Refer to user-defined table 0043 - Condition code for suggested values. This field is defined by HCFA or other regulatory agencies.

6.4.10.8 Covered days - (23) (NM) 00537

Definition: This field contains UB82 Field 23. This field is defined by HCFA or other regulatory agencies.

6.4.10.9 Non-covered days - (24) (NM) 00538

Definition: This field contains UB82 Field 24. This field is defined by HCFA or other regulatory agencies.

6.4.10.10 Value amount and code (CM) 00539

Components: <value code (IS)> ^ <value amount (NM)>

Definition: The pair in this field can repeat up to eight times (46A, 47A, 48A, 49A, 46B, 47B, 48B, and 49B). Refer to user-defined table 0153 - Value code for suggested values. This field is defined by HCFA or other regulatory agencies.

6.4.10.11 Number of grace days (90) (NM) 00540

Definition: This field contains UB82 Field 90. This field is defined by HCFA or other regulatory agencies.

6.4.10.12 Spec program indicator (44) (CE) 00541

Components: <identifier (ST)> ^ <text (ST)> ^ <name of coding system (ST)> ^ <alternate identifier (ST)> ^ <alternate text (ST)> ^ <name of alternate coding system (ST)>

Definition: This field contains the special program indicator. UB82 Field 44. This field is defined by HCFA or other regulatory agencies.

6.4.10.13 PSRO/UR approval indicator (87) (CE) 00542

Components: <identifier (ST)> ^ <text (ST)> ^ <name of coding system (ST)> ^ <alternate identifier (ST)> ^ <alternate text (ST)> ^ <name of alternate coding system (ST)>

Definition: This field contains the PSRO/UR approval indicator. UB82 field 87. This field is defined by HCFA or other regulatory agencies.

6.4.10.14 PSRO/UR approved stay-fm (88) (DT) 00543

Definition: This field contains the PSRO/UR approved stay date (from). UB82 Field 88. This field is defined by HCFA or other regulatory agencies.

6.4.10.15 PSRO/UR approved stay-to (89) (DT) 00544

Definition: This field contains the PSRO/UR approved stay date (to). UB82 Field 89. This field is defined by HCFA or other regulatory agencies.

6.4.10.16 Occurrence (28-32) (CM) 00545

Components: <occurrence code (IS)> ^ <occurrence date (DT)>

Definition: The set of values in this field can repeat up to five times. UB82 Fields 28-32. This field is defined by HCFA or other regulatory agencies.

6.4.10.17 Occurrence span (33) (CE) 00546

Components: <identifier (ST)> ^ <text (ST)> ^ <name of coding system (ST)> ^ <alternate identifier (ST)> ^ <alternate text (ST)> ^ <name of alternate coding system (ST)>

Definition: UB82 Field 33. This field is defined by HCFA or other regulatory agencies.

6.4.10.18 Occur span start date (33) (DT) 00547

Definition: This field contains the occurrence span start date. UB82 Field 33. This field is defined by HCFA or other regulatory agencies.

6.4.10.19 Occur. span end date (33) (DT) 00548

Definition: This field contains the occurrence span end date. UB82 Field 33. This field is defined by HCFA or other regulatory agencies.

6.4.10.20 UB-82 locator 2 (ST) 00549

Definition: Defined by UB-82 HCFA specification.

6.4.10.21 UB-82 locator 9 (ST) 00550

Definition: Defined by UB-82 HCFA specification.

6.4.10.22 UB-82 locator 27 (ST) 00551

Definition: Defined by UB-82 HCFA specification.

6.4.10.23 UB-82 locator 45 (ST) 00552

Definition: Defined by UB-82 HCFA specification.

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