Step 10

Training Video

This chapter is extremely useful when you find an error on your scoring report that you want to locate in ClaimGear and correct.


The scoring report provides a box number and lists the data entry error.  Locate this box number on the Specs (see page 83).  The Specs provide instructions on how to navigate through ClaimGear  to the exact field an error has occurred.  Make the corrections and click the Save button.



 

UB-04 (CMS-1450) Claim Form

Below is an example of the UB-04 (CMS-1450) claim form.  The box numbers referred to on the scoring report and on the Specs are also the box (FL) numbers on the UB-04 claim form.


 
UB-04 Specs
 

CLAIMGEAR  UB-04 SPECS

BOX              DESCRIPTION OF FIELD ON FORM AND IN CLAIMGEAR

                      LOCATION OF FIELD IN CLAIMGEAR

 

 

 

1

 

Practice Information

 

 

Practice, Find, enter Information

 

 

 

2

 

Pay to Information

 

 

Not applicable

 

 

 

3a

 

Patient Control No.

 

 

Claim –F1, 1 Claim # automatically generated by ClaimGear

3b

 

Medical Record No.

 

 

Patient –F2, Account # automatically generated by ClaimGear

 

 

 

4

 

Type of Bill

 

 

Claim –F1, 1 Claim tab, enter Type of Bill

 

 

 

5

 

Federal Tax Number

 

 

Provider, Find, Select Provider, Provider Information tab, enter Employer Identification #

 

 

 

6

 

Statement Covers Period From and Through

 

 

Claim –F1, 3 Additional Info tab, enter Statement Covers “From” and “To” date

 

 

 

7

 

Unlabeled

 

 

This field on the UB-04 form is not currently used.

 

 

 

8a

 

Patient ID

 

 

Automatically generated by ClaimGear

8b

 

Patient Name

 

 

Patient –F2, 1 Patient tab, enter Last Name, First, MI

 

 

 

9

 

Patient Address

 

 

Patient –F2, 1 Patient tab, enter Address, City, State, and Zipcode

 

 

 

10

 

Patient Birthdate

 

 

Patient –F2, 1 Patient tab, enter Birthdate

 

 

 

11

 

Patient Sex

 

 

Patient –F2, 1 Patient tab, enter Sex

 

 

 

12

 

Admission Date

 

 

Claim –F1, 3 Additional Info tab, enter Admission Date

 

 

 

13

 

Admission Hour

 

 

Claim –F1, 3 Additional Info tab, enter Admission Hour

14

 

Admission Type

 

 

Claim –F1, 3 Additional Info tab, enter Admission Type

 

 

 

15

 

Admission Source

 

 

Claim –F1, 3 Additional Info tab, enter Admission Source

 

 

 

16

 

Discharge Hour

 

 

Claim –F1, 3 Additional Info tab, enter Discharge Hour

 

 

 

17

 

Patient Discharge Status

 

 

Claim –F1, 3 Additional Info tab, enter Patient Status

 

 

 

18-28

 

Condition Codes

 

 

Claim –F1, 3 Additional Info tab, Condition tab, enter Condition Codes

 

 

 

29

 

Accident State

 

 

Claim –F1, 3 Additional Info tab, enter auto Accident State

 

 

 

30

 

Unlabeled

 

 

This field on the UB-04 form is not currently used.

 

 

 

31-35

 

Occurrence

a-b

 

Claim –F1, 3 Additional Info tab, Occurrence tab, enter Occurrence Code and Date

 

 

 

36

 

Occurrence Span

 

 

Claim –F1, 3 Additional Info tab, Occurrence Span tab, enter Occurrence Code and Dates

 

 

 

37

 

Unlabeled

 

 

This field on the UB-04 form is not currently used.

 

 

 

38

 

Responsible Party Name and Address

 

a-c

Patient –F2, 2 Insured tab, Insured tab, enter Insured Name and Address

 

 

 

39-41

 

Value Code

a-d

 

Claim –F1, 3 Additional Info tab, Value tab, enter Value Code and Amount

 

 

 

42

 

Revenue Code

 

 

Claim –F1, 2 Charges tab, enter Rev Code

 

 

 

43

 

Description

 

 

Claim –F1, 2 Charges tab, "Use Description From" and enter Rev Code or HCPCS

 

 

 

44

 

HCPCS/Rates/HIPPS Rate Codes

 

 

Claim –F1, 2 Charges tab, enter HCPCS Code

44x

 

Payment Information - InsPay  InsAdj  InsAllow

 

 

Payment –F3, 3 EOB Posting tab, Find EOB and Patient, correct payment, adjustment, or allowed

 

 

 

45

 

Service Date

 

 

Claim –F1, 2 Charges tab, enter Service Dates “From” and “To”

46

 

Service Units

 

 

**Claim –F1, 2 Charges tab, enter Units

 

 

 

47

 

Total Charge

 

 

**Claim –F1, 2 Charges tab, enter Total Charge (=Unit Price X Units)

 

 

 

48

 

Non-Covered Charges

 

 

Not applicable

 

 

 

49

 

Unlabeled

 

 

This field on the UB-04 form is not currently used.

 

 

 

50

 

Payer Name

a

 

*Patient –F2, 2 Insured tab, Payers tab, enter Payer 1 by New Payer or Find Payer button

b

 

*Patient –F2, 2 Insured tab, Payers tab, enter Payer 2 by New Payer or Find Payer button

b

or

*Patient –F2, 3 Other Insured tab, enter Payer 3 by New Payer or Find Payer button

c

 

*Patient –F2, 3 Other Insured tab, enter Payer 3 by New Payer or Find Payer button

 

 

 

51

 

Health Plan ID

a-c

 

Payer –F6, Find and Select, Provider ID Number tab, select Individual Number

 

 

 

52

 

Release of Information

a-c

 

Automatically generated by ClaimGear

 

 

 

53

 

Assignment of Benefits

a-c

 

Claim –F1, 3 Additional Info tab, enter “Yes, The provider accepts the assignment of benefits”

 

 

 

54

 

Prior Payments

 

 

Payment –F3, 3 EOB Posting tab, Find, Search, Select Patient, correct information

 

 

 

55

 

Estimated Amount Due

 

 

Correct Box 47 [Charge(s)] to fix this box.

 

 

 

56

 

NPI

 

 

Choose different physician: Claim –F1, 1 Claim tab, and Select Billing Provider

 

 

 

57

 

Other Provider ID (primary & secondary)

 

 

Not applicable

 

 

 

58

 

Insured's Name

a

 

*Patient –F2, 2 Insured tab, enter Last Name, First, MI

b

 

*Patient –F2, 2 Insured tab, enter Last Name, First, MI

b

or

*Patient –F2, 3 Other Insured tab, enter Last Name, First, MI

c

 

*Patient –F2, 3 Other Insured tab, enter Last Name, First, MI

 

 

 

59

 

Patient's Relationship

a

a

*Patient –F2, 2 Insured tab, enter “Patient relationship to the insured?”

b

b

*Patient –F2, 2 Insured or Other Insured tab, enter “Patient relationship to the other insured?”

  

60

 

Insured's Unique ID

a

 

*Patient –F2, 2 Insured tab, Payers tab, enter Payer 1 MemberID #

b

 

*Patient –F2, 2 Insured tab, Payers tab, enter Payer 2 MemberID #

b

or

*Patient –F2, 3 Other Insured tab, enter Payer 3 MemberID #

c

 

*Patient –F2, 3 Other Insured tab, enter Payer 3 MemberID #

 

 

 

61

 

Insurance Group Name

a-c

a

Payer –F6, 1 Payer tab, select Plan Name

 

 

 

62

 

Insurance Group Number

a

 

*Patient –F2, 2 Insured tab, Payers tab, enter Payer 1 Group #

b

 

*Patient –F2, 2 Insured tab, Payers tab, enter Payer 2 Group #

b

or

*Patient –F2, 3 Other Insured tab, enter Payer 3 Group #

c

 

*Patient –F2, 3 Other Insured tab, enter Payer 3 Group #

 

 

 

63

 

Treatment Authorization Code

a-c

 

Claim –F1, 1 Claim tab, enter Authorization #, and click the Copy Authorization to Claim button

 

 

 

64

 

Document Control Number

a-c

 

Not applicable

 

 

 

65

 

Employer Name

a

 

*Patient –F2, 2 Insured tab, Employer tab, enter Employer Name

b

 

*Patient –F2, 2 Insured tab, Employer tab, enter Employer Name

b

or

*Patient –F2, 3 Other Insured tab, enter Employer Name

c

 

*Patient –F2, 3 Other Insured tab, enter Employer Name

 

 

 

66

 

Dx Version Qualifier

 

 

Automatically generated by ClaimGear

 

 

 

67

 

Principal Diagnosis Code

 

 

Claim –F1, 3 Additional Info tab, Diagnosis tab, enter Principal code

 

 

 

67

 

Other Diagnosis

a-q

 

Claim –F1, 3 Additional Info tab, Diagnosis tab, enter Other code(s)

 

 

 

68

 

Unlabeled

 

 

This field on the UB-04 form is not currently used.

 

 

 

69

 

Admitting Diagnosis Code

 

 

Claim –F1, 3 Additional Info tab, Diagnosis tab, enter Admit code

 

 

 

70

 

Patient's Reason for Visit Code

 

 

Claim –F1, 3 Additional Info tab, Diagnosis tab, enter Patient Reason code

 

 

 

71

 

PPS Code

 

 

Not applicable

 

72

 

E-code (external cause code)

a-c

 

Claim –F1, 3 Additional Info tab, Diagnosis tab, enter E code(s)

 

 

 

73

 

Unlabeled

 

 

This field on the UB-04 form is not currently used.

 

 

 

74

 

Principal Procedure Code/Date

 

 

Claim –F1, 3 Additional Info tab, Procedure tab, enter Principal Code and Date

 

 

 

74

 

Other Procedure Code/Date

a-e

 

Claim –F1, 3 Additional Info tab, Procedure tab, enter Other Procedure Code and Date

 

 

 

75

 

Unlabeled

 

 

This field on the UB-04 form is not currently used.

 

 

 

76

 

Attending

 

 

Claim –F1, 1 Claim tab, and Select Attending Provider

 

 

 

77

 

Operating

 

 

Claim –F1, 1 Claim tab, and Select Operating Provider

 

 

 

78

 

Other

 

 

Claim –F1, 1 Claim tab, and Select Referring Provider

 

 

 

79

 

Other

 

 

Claim –F1, 1 Claim tab, and Select Other Provider

 

 

 

80

 

Remarks

 

 

Claim –F1, 3 Additional Info tab, Remarks tab, free field for remarks

 

 

 

81

 

Code-Code

 

 

Not applicable

 

 

 

NA

 

Claim - Not Found

 

 

One or more are incorrect, fix and rescore.  Patient Name (box 2), DOB (box 3), and DOS (box 24a).

 

 

See page 71 of this manual for a detailed description.

 

 

 

NA

 

Charge – Not Found

 

 

1 or more are incorrect, fix and rescore.  DOS (box 24a) and Charges (24d).

 

 

See page 70 of this manual for a detailed description.

 

 

 

*

 

Information on the Patient –F2, 2 Insured tab OR 3 Other Insured tab

 

 

If any information on these two screens has been updated after initial entry,

 

 

go to 4 Misc. Info. tab, check B, and click the Save button.

 

 

 

**

 

Unit Price or Units

 

 

Claim –F1, 1 Claim tab, uncheck the "Always auto-calculate totals"