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6.4.11 UB2 - UB92 data segment

The UB2 segment contains data necessary to complete UB92 bills. Only UB92 fields that do not exist in other HL7 defined segments appear in this segment. Just as with the UB82 billing, Patient Name and Date of Birth are required; they are included in the PID segment and therefore do not appear here. When the field locators are different on the UB92, as compared to the UB82, the element is listed with its new location in parentheses ( ).

Figure 6-11. UB2 attributes

SEQ

LEN

DT

OPT

RP/#

TBL#

ITEM#

ELEMENT NAME

1

4

SI

O



00553

Set ID - UB2

2

3

ST

O



00554

Co-Insurance Days (9)

3

2

IS

O

Y/7

0043

00555

Condition Code (24-30)

4

3

ST

O



00556

Covered Days (7)

5

4

ST

O



00557

Non-Covered Days (8)

6

11

CM

O

Y/12

0153

00558

Value Amount & Code

7

11

CM

O

Y/8


00559

Occurrence Code & Date (32-35)

8

28

CM

O

Y/2


00560

Occurrence Span Code/Dates (36)

9

29

ST

O

Y/2


00561

UB92 Locator 2 (State)

10

12

ST

O

Y/2


00562

UB92 Locator 11 (State)

11

5

ST

O



00563

UB92 Locator 31 (National)

12

23

ST

O

Y/3


00564

Document Control Number

13

4

ST

O

Y/23


00565

UB92 Locator 49 (National)

14

14

ST

O

Y/5


00566

UB92 Locator 56 (State)

15

27

ST

O



00567

UB92 Locator 57 (National)

16

2

ST

O

Y/2


00568

UB92 Locator 78 (State)

17

3

NM

O



00815

Special Visit Count

6.4.11.0 UB2 field definitions

6.4.11.1 Set ID - UB2 (SI) 00553

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.

6.4.11.2 Co-insurance days (ST) 00554

Definition: This field contains UB92 field 9. This field is defined by HCFA or other regulatory agencies.

6.4.11.3 Condition code (IS) 00555

Definition: The code in this field can repeat up to seven times. UB92 fields 24-30. Refer to user-defined table 0043 - Condition code for suggested values. This field is defined by HCFA or other regulatory agencies.

6.4.11.4 Covered days (ST) 00556

Definition: This field contains UB92 field 7. This field is defined by HCFA or other regulatory agencies.

6.4.11.5 Non-covered days (ST) 00557

Definition: This field contains UB92 field 8. This field is defined by HCFA or other regulatory agencies.

6.4.11.6 Value amount and code (CM) 00558

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

Definition: The pair in this field can repeat up to twelve times. UB92 fields 39a, 39b, 39c, 39d, 40a, 40b, 40c, 40d, 41a, 41b, 41c, and 41d. Refer to user-defined table 0153 - Value code for suggested values. This field is defined by HCFA or other regulatory agencies.

6.4.11.7 Occurrence code & date (CM) 00559

Components: <identifier (ST) & text (ST) & name of coding system (ST) & alternate identifier (ST) & alternate text (ST) & name of alternate coding system (ST)> ^ <occurrence date (DT)>

Definition: The set of values in this field can repeat up to eight times. UB92 fields 32a, 32b, 33a, 33b, 34a, 34b, 35a, and 35b. This field is defined by HCFA or other regulatory agencies.

6.4.11.8 Occurrence span code and dates (CM) 00560

Components: <identifier (ST) & text (ST) & name of coding system (ST) & alternate identifier (ST) & alternate text (ST) & name of alternate coding system (ST)> ^ <occurrence span start date (DT)> ^ <occurrence span stop date (DT)>

Definition: This field can repeat up to two times. UB92 field 36a, 36b. This field is defined by HCFA or other regulatory agencies.

6.4.11.9 UB92 field 2, designated for state use (ST) 00561

Definition: The value in this field may repeat up to two times. This field is defined by HCFA or other regulatory agencies.

6.4.11.10 UB92 field 11, designated for state use (ST) 00562

Definition: The value in this field may repeat up to two times.

6.4.11.11 UB92 field 31, designated for national use (ST) 00563

Definition: Defined by HCFA or other regulatory agencies.

6.4.11.12 Document control number (ST) 00564

Definition: This field contains the number assigned by payor that is used for rebilling/adjustment purposes. It may repeat up to three times. UB92 field 37

6.4.11.13 UB92 field 49, designated for national use (ST) 00565

Definition: This field may repeat up to twenty-three times. This field is defined by HCFA or other regulatory agencies.

6.4.11.14 UB92 field 56, designated for state use (ST) 00566

Definition: This field may repeat up to five times.

6.4.11.15 UB92 field 57, designated for national use (ST) 00567

Definition: Defined by UB-92 HCFA specification.

6.4.11.16 UB92 field 78, designated for state use (ST) 00568

Definition: This field may repeat up to two times.

6.4.11.17 Special visit count (NM) 00815

Definition: This field contains the total number of special therapy visits.

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