UB-92/CMS-1450 Paper Form Instructions
The following information must be completed or the claim may be returned to you
unprocessed or denied for insufficient information.
UB92 /
CMS 1450
Field
Number
1
UB92 / CMS 1450
Field Name
/Description
Provider Name, Address
and Telephone Number
2
3
Unlabeled Field
Patient Control Number
4
Type of Bill
5
Fed. Tax No.
6
Statement Covers Period
From and Through
7
Cov’d/Covered Days
8
N-Cov’d/Noncovered
Days
C-I D./Coinsurance Days
9
10
L-R D./Lifetime Reserve
Days
11
12
13
Unlabeled Field
Patient’s Name (Last, First
Name, Middle Initial)
Patient Address
14
Birth Date
Completion Instructions
Enter the name of the Facility submitting the
bill and the complete billing address and
telephone number, which matches the W-9
submitted to ValueOptions.
Not Applicable
Enter the unique number assigned by the
Facility for the Patient.
Enter a valid 3-digit Type of Bill code, which
provides specific information about the
services rendered. Refer to “UB-92
Reference Material” for valid codes.
Enter the nine-digit Employer Identification
Number (EIN) for the Provider indicated in
box 1, which is the ID under which the
provider agreement is contracted with VBHPA. This ID is used to ensure accurate
reimbursement for services and is also used
for reporting earnings to the IRS.
Enter the beginning and ending date of
services for the period reflected on the claim
in MMDDCCYY format.
Enter the number of inpatient days covered
for the billing period noted in Field 6.
Enter the number of inpatient days not
covered by the primary Payer.
Enter the number of the inpatient Medicare
days occurring after the 60th day and before
the 91st day in a single episode.
Enter the number of lifetime reserve days
used during the billing period noted on the
claim.
Not Applicable
Enter the Patient Name (Last, First Name, and
Middle Initial).
Enter the complete mailing address of the
Patient. Include the street number and name,
post office box or rural route number and
apartment number if applicable, city, state and
zip code.
Enter the Patient’s Date of Birth in
MMDDCCYY format.
UB92 /
CMS 1450
Field
Number
15
Sex
16
Marital Status
17
Admission Date
18
Admission Hour
19
Admission Type
20
Admission Source
21
D. HR/Discharge Hour
22
STAT/Patient Status
23
Medical Record No.
24 – 30
31
32a, b
Condition Codes
Unlabeled Field
Occurrence Code and Date
33a, b
Occurrence Code and Date
34a, b
Occurrence Code and Date
35a, b
Occurrence Code and Date
36a, b
Occurrence Span Code
and From/Through Date
Unlabeled Field
Responsible Party Name
and Address
Value Codes/Amount
37a, b, c
38
39a, b, c, d
UB92 / CMS 1450
Field Name
/Description
Completion Instructions
Enter the sex of the Patient. Refer to “UB-92
Reference Material” for valid codes.
Enter the marital status of the patient on the
date of the admission. Refer to “UB-92
Reference Material” for valid codes.
Enter the original date the Patient was
admitted for care in MMDDCCYY format.
Enter the admission hour in Military Standard
Time (e.g., 00:00 to 24:00), if applicable.
Enter the admission type if applicable. Refer
to “UB-92 Reference Material” for valid
codes.
Enter the appropriate Admission Source
Code. The Newborn coding structure for
admission source must be used when the
Admission Type in Field 19 indicates “4”.
Refer to “UB-92 Reference Material” for
valid codes.
Enter the hour in which the patient was
discharged from inpatient care if applicable.
Enter the applicable code indicating the
patient’s disposition as of the ending date of
service for the period of care. Refer to “UB92 Reference Material” for valid codes.
Enter the number assigned by the Provider to
the patient’s medical or health record.
Enter a valid Condition Code if applicable.
Not Applicable
Enter a valid Occurrence Code and date if
applicable. Enter the date in MMDDCCYY
format.
Enter a valid Occurrence Code and date if
applicable. Enter the date in MMDDCCYY
format.
Enter a valid Occurrence Code and date if
applicable. Enter the date in MMDDCCYY
format.
Enter a valid Occurrence Code and date if
applicable. Enter the date in MMDDCCYY
format.
Required if an Occurrence Span Code
entered; enter in MMDDCCYY format.
Not Applicable
Enter the name and address of the party
responsible for payment of the bill.
Enter a valid Value Code and amount if
UB92 /
CMS 1450
Field
Number
40a, b, c, d
UB92 / CMS 1450
Field Name
/Description
Value Codes/Amount
41a, b, c, d
Value Codes/Amount
42
Rev. CD./Revenue Code
43
Description
44
Procedures, Services, or
Supplies
HIPAA compliant codes
45
Serv. Date/Service Date
46
47
Serv. Units/Service Units
Total Charges
48
Non-Covered Charges
49
50a, b, c
Unlabeled Field
Payer
51a, b, c
Provider No./Provider
Number
Completion Instructions
applicable.
Enter a valid Value Code and amount if
applicable.
Enter a valid Value Code and amount if
applicable.
Enter the applicable VBH-PA contracted
revenue codes for the services rendered.
Revenue Code 0001 must be the final entry on
all bills to identify total claim charges billed.
Enter the corresponding description of the
revenue code indicated in Field 43 lines 1-23.
Enter a valid HIPAA compliant procedure
code. If the code is followed by modifiers, be
sure that you include ALL modifiers in the
order they appear on the Provider grid. Your
contract amendments should contain the
procedure codes/modifiers that you are
contracted to perform and bill.
Enter the date the service was rendered in
MMDDCCYY format
Enter the service units for each service billed.
Enter the amount equal to the per unit charge
for the related revenue code. The total of all
covered and non-covered charges billed must
add up to the dollar amount reported on line
item denoting Revenue Code 001.
Enter the total non-covered charges for the
primary Payer if applicable for each service
billed.
Not Applicable
If VBH-PA is the ONLY insurance coverage,
please leave this field BLANK. (Do not write
in “none” or “N/A”. If there is another
Primary insurance such as Medicare or Blue
Cross, etc., please list in this field/box all
insurance coverage. In Priority Sequence, list
the names of the insurance companies from
which the Provider expects to receive
payment for these services. Please do NOT
list the Physical Health Insurance Plans
such as Gateway, Unison, Best, or a
member’s car insurance company.
Enter the number assigned to the Provider by
the Payer indicated in Field 50, if known.
Required if VBH-PA is Primary, Secondary
or Tertiary Payer.
UB92 /
UB92 / CMS 1450
CMS 1450
Field Name
Field
/Description
Number
52a, b, c
Rel. Info./Release of
Information Authorization
Indicator
53a, b, c
Asg. Ben./Assignment of
Benefits
54a, b. c
Prior Payments
55a, b, c
Est. Amount Due
56
57
58a, b, c
61a, b, c
Unlabeled Field
Unlabeled Field
Insured’s Name (Last, First
Name, Middle Initial)
P. Rel/Patient’s
Relationship to Insured
Cert – SSN – HIC – ID
No./Certificate – Social
Security Number – Health
Insurance Claim
Identification Number
Group Name
62a, b, c
Insurance Group No.
63a, b, c
Treatment Authorization
Codes
ESC (Employment Status
Code)
Employer Name
Employer Location
Prin. Diag. CD./Principal
Diagnosis Code
59a, b, c
60a, b, c
64a, b, c
65a, b, c
66a, b, c
67
68 – 75
Other Diag. Codes/Other
Diagnosis Code
Completion Instructions
Enter the appropriate code denoting whether
the Provider has on file a signed statement
from the Member to release information.
Refer to “UB-92 Reference Material” for
valid codes.
VBH-PA contracted provider agreements
outline that reimbursement is always made to
the provider/facility, therefore benefit
assignment is not required.
Enter any prior payment amounts the Facility
has received toward payment of this bill for
the Payer indicated in Field 50 lines a, b, c.
Enter the estimated amount due from the
Payer indicated in Field 50 lines a, b, c.
Not Applicable
Not Applicable
Enter the Member’s Name (Last, First Name,
and Middle Initial).
Not Applicable
Enter the Member’s identification number
assigned by the Payer organization.
 Social Security Number (SSN)
 Medicaid Number
Enter the group or plan name of the Primary
Payer (Southwest PA HealthChoices), or
Secondary and/or Tertiary Payer through
which the coverage is provided to the
Member.
Enter the plan or group number for the
Primary, Secondary and Tertiary Payer.
Enter the authorization number assigned by
the Payer indicated in Field 50 if known.
Not Applicable
Not Applicable
Provider ID; Vendor ID
Enter a valid ICD-9 diagnosis code (including
the fourth and fifth digits if applicable) that
describes the principal diagnosis for the
services rendered.
Enter a valid ICD-9 diagnosis code (including
the fourth and fifth digits if applicable) for
any other conditions that exist for the services
rendered.
UB92 /
UB92 / CMS 1450
CMS 1450
Field Name
Field
/Description
Number
76
Adm. Diag. CD./Admitting
Diagnosis Code
77
E-Code
78
79
Unlabeled Field
P.C./Procedure Code
Method Used
80
Principle Procedure
Code/Date
81
Other Procedure Code/Date
82
Inpatient or ResidentialAttending Phys.
(Authorized Billing
Psychiatrist) name & PA
Department of State
License #
83
85
Other Phys. ID/Other
Physician Identification
Number
Name and Address of
Facility Where Services
were rendered.
Provider Representative
86
Date
84
Completion Instructions
Enter a valid ICD-9 diagnosis code (including
the fourth and fifth digit if applicable) that
describes the diagnosis at the time of the
admission.
Enter a valid ICD-9 diagnosis code (including
the fourth and fifth digits if applicable) for the
external cause of injury, poisoning or adverse
effect.
Not Applicable
Enter the corresponding code, which denotes
the medical coding system used to complete
the claim form.
Enter a valid ICD-9 code and date for the
principal procedure performed during the
period covered by the bill.
Enter additional ICD-9 codes and dates to
identify the significant procedures performed
during the statement from and through dates.
Enter the name of the facility and the assigned
number of the licensed Physician or other
professional who has primary responsibility
for the Patient’s behavioral health care. The
format should be 2 alpha and 6 numeric
characters, followed by possibly 1 additional
alpha character.
Enter the name and/or number of the licensed
Physician other than the attending Physician
who treated the Patient.
Enter name and address where service is
provided, even if the service address is the
same as the billing address entered in Box 1.
Enter the signature of an authorized
representative noting the Physician’s
authorization is in effect. A stamp or facsimile
of the Provider’s representative signature is
acceptable.
Enter the date the bill is submitted to the
Payer organization in MMDDCCYY format.