Billing Claim Form Guidelines
Blue Cross of California is committed to delivering excellent service. Part of that commitment includes
compliance with and support of the new universal claim billing forms. Since October 1st, 2006, Blue Cross of
California has been accepting new universal claim billing forms. Professional and facility billing forms now permit the use
of the National Provider Identifier (NPI) number. We urge providers and their office staff to review these forms and
identify the changes that have been made. The CMS-1500 (12/90) formerly known as the HCFA-1500 is now referred to as
the CMS-1500 (08/05) form and the UB-92 is now referred to as the UB-04 form. These new forms will require you to
align on-line data entry screens with the new CMS-1500 (08/05) format so that information will be displayed in the correct
fields. Below are examples of the new claim forms, with all changes highlighted. A frequently asked questions document
is available to assist your transition to the new universal claim billing forms.
When submitting electronic transactions with NPIs, please refer to the Revised NPI Contingency Period
Companion Guide, which outlines the changes required for the HIPAA transactions for Blue Cross of California:
Below is an example of the CMS-1500 (08/05) form (formerly the HCFA-1500):
NPI # of referring provider
Qualifier used to identify
when a number other than the
NPI is being used.
Grey shaded area is used for
numbers other than the NPI,
such as the provider’s legacy
ID or BCBS number. The
rendering provider’s NPI is
placed in 24J (unshaded).
This area should not be used
to bill 12 lines of service.
The shaded area will be used
for numbers that are other
than the NPI for the
facility/billing provider. The
non-shaded area will house
the provider’s NPI.
The tax ID must align
with the billing
provider’s NPI ( 33A).
Indicates with Y or N if
services were rendered in
an emergency situation.
Field name change
** PPO Networks such as WPPA and Preferred One, who had previously used Field 24 I for their repricing
information, will now use Repricing Cover Sheets.
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Below is an example of a UB-04 Form (formerly the UB-92 Form):
Due to the number of changes to the UB-04 Form, the information below is presented in two sections.
Section 1
Section 2
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Section 1 of the UB-04:
Fields that have changed, have been added, or are no longer in use are highlighted with the following colors:
• Yellow indicate a new field
• Teal indicates a change in name or location of a field previously located on the UB-92 Form
• Pink highlights indicate a field that is no longer in use
Fields that are not highlighted have not changed.
•
•
•
Field 2 on the UB-04 claim form is used to indicate a “Pay To” name and address.
Field 3 is now 2 separate fields. Field 3a houses the Patient Control Number and 3b houses the Medical Records
Number.
Field changes (placement on form or name change) include:
o
o
o
o
o
o
o
o
o
o
o
8-8b
= Patient Name and ID
9a-9e = Patient Address including Street, City, State, Zip and Country Code
10
= Patient Birth Date
11
= Patient Sex
12 – 13 = Admission Date and Hour
14 – 15 = Type and Source of Admission
16 – 17 = Discharge Hour and Status
18 – 23 = Condition Codes
29
= Accident State (2 Letter Identifier of State)
31 – 34 = Occurrence Codes/Dates
35 – 36 = Occurrence Span
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Section 2 of the UB-04:
Fields that have changed, have been added, or are no longer in use are highlighted with the following colors:
• Yellow indicate a new field
• Teal indicates a change in name or location of a field previously located on the UB-92 Form
• Pink highlights indicate a field that is no longer in use
Fields that are not highlighted have not changed.
Field 23 allows providers to indicate the number of pages billed and which of the pages is being referenced and to indicate
the date the service billing form was created
• Field 56 is the location for placement of the provider’s NPI number
• Fields 76-79 are the locations for the Attending, Operating and Other Physicians NPI Numbers to be listed, along
with their legacy information.
• Field changes (placement on form or name change) include:
o 51 a – c = Health Plan ID
o 54 a – c = Prior payments from Primary, Secondary or Tertiary Insurances
o 55 a – c = Estimated amounts due from Primary, Secondary or Tertiary Insurances
o 57 a – c = Other provider ID NPI’s and Legacy ID numbers
o 60 a – c = Insured’s Unique ID Number (SSN, Medicare, etc) for Primary, Secondary and Tertiary
Insurances
o 64 a – c = Document control number
o 66
= Diagnosis Version Qualifier
o 67 a – q = Principal Diagnosis Code (field 67) and additional diagnosis (a-q)
o 69
= Admitting Diagnosis Code
o 70 a – c = Patient’s Reason for Visit
o 71
= PPS Code
o 72 a – c = External Cause of Injury
o 74 a – e = Principle or Other Procedure Codes and Dates
o 76 – 79 = Expanded fields for NPI and legacy provider information
o 80
= Field for any additional remarks a provider may need to make.
o 81a – d = Quality Codes and Values including the taxonomy code
** For more detailed information on changes made to the CMS1500/UB04 forms please refer to the On Line Claim
Manual – Hospital Claim. **
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