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
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.
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.
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.
Definition: This field contains UB82 Field 41. This field is defined by HCFA or other regulatory agencies.
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.
Definition: This field contains UB82 Field 25. This field is defined by HCFA or other regulatory agencies.
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.
Definition: This field contains UB82 Field 23. This field is defined by HCFA or other regulatory agencies.
Definition: This field contains UB82 Field 24. This field is defined by HCFA or other regulatory agencies.
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.
Definition: This field contains UB82 Field 90. This field is defined by HCFA or other regulatory agencies.
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.
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.
Definition: This field contains the PSRO/UR approved stay date (from). UB82 Field 88. This field is defined by HCFA or other regulatory agencies.
Definition: This field contains the PSRO/UR approved stay date (to). UB82 Field 89. This field is defined by HCFA or other regulatory agencies.
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.
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.
Definition: This field contains the occurrence span start date. UB82 Field 33. This field is defined by HCFA or other regulatory agencies.
Definition: This field contains the occurrence span end date. UB82 Field 33. This field is defined by HCFA or other regulatory agencies.
Definition: Defined by UB-82 HCFA specification.
Definition: Defined by UB-82 HCFA specification.
Definition: Defined by UB-82 HCFA specification.
Definition: Defined by UB-82 HCFA specification.