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UB04 Mapping 2017-03-17
Element #DescriptionResourceElementCommentsNotes
1Provider Name and AddressClaim.organization->Organizationname and address
2Pay-To Name and AddressClaim.payee.party->Patient|RelatedPerson|Organizationname and address
3aPatient Control NumberClaim.patient->Patientidentifierwhere type='PCN' (add to valueset)
3bMedical Record NumberClaim.patient->Patientidentifierwhere type='MR'
4Type of BillClaimsubTypeuse CMS Bill Type Codes
5Federal Tax ID NumberClaim.organization->OrganizationidentifierWhere type ="TAX"
6Statement Covers PeriodClaimbillablePeriod
7Future Use
8aPatient IDClaim.patient->Patientidentifierwhere type="???"
8bPatient NameClaim.patient->Patientname
9a-ePatient AddressClaim.patient->Patientaddress
10Patient BirthdateClaim.patient->PatientbirthDate
11Patient SexClaim.patient->Patientgender
12Admission DateClaimhospitalization.start
13Admission HourClaimhospitalization.start
14Type of Admission/VisitClaiminformation[n].code.category='info', .code.coding.system="type of admission codes"Include a resource?
15Source of AdmissionClaiminformation[n].code.category='info', .code.coding.system="source of admission codes"Include a resource?
16Discharge HourClaimhospitalization.end
17Patient Discharge StatusClaiminformation[n].code.category='discharge', .code.coding.system="discharge codes"Include a resource?
18-28Condition CodesClaiminformation[n].code.category='info', .code.coding.system="condition codes"Claim related.
29Accident StateClaiminformation[n].code.category='info', .code.coding.system="accident state codes"Claim related.
30Future Use
31-34Occurrence Codes and DatesClaiminformation[n].code and .timing.date.category='info', .code.coding.system="Occurence system", .code.coding.code=" Occurance code"Claim related or a resource?
35-36Occurrence Span Codes and DatesClaiminformation[n].code and .timing.period.category='info', .code.coding.system="Occurence system", .code.coding.code=" Occurance code"Claim related or a resource?
37Future Use
38Responsible Party Name and AddressClaim.information[n].valueReference-> Patient|RelatedPerson|Organizationname and address.category='info', .code.coding.system="UB40 information codes, .code.coding.code="responsible"Claim related or is this really a guarantor on the Account?
39-41Value Codes and AmountsClaiminformation[n].code and .valueQuantity.category='info', .code.coding.system="Value system", .code.coding.code=" Value code"
42Revenue CodeClaimitem[n].revenue.coding.code
43Revenue Code DescriptionClaimitem[n].revenue.coding.display
43aNDC codeClaiminformation[n].code.coding[1].codesee below for NDC code
44HCPCS/RatesClaimservice/unit
45Service DateClaimitem[n].servicedDate
46Units of ServiceClaimitem[n].quantity
47Total Charges by Revenue CodeClaimamount
48Non-Covered ChargesClaimitem.extensionExtension: non-covered charges amount
49Future Use
50Payer Identification (Name)Claim->insurer->Organizationname
51Health Plan Identification NumberClaim.insurance[n].coverageidentifier.value
52Release of Info CertificationClaiminformation[n].code .category='info', .code.coding.system="UB40 information codes, .code.coding.code="roi_cert"Claim related or a resource?
53Assignment of Benefit CertificationClaiminformation[n].code .category='info', .code.coding.system="UB40 information codes, .code.coding.code="assignment"Claim or Coverage related?
54Prior PaymentsClaim.insurance[n].claimResponsetotalBenefit
55Estimated Amount DueClaiminformation[n].code and .quantity.category='info', .code.coding.system="UB40 information codes, .code.coding.code="amtdue"Claim related.
56NPIClaim.provider->Practitioneridentifierwith type='NPI'
57Other Provider IDsClaim.careTeam[n].provider->Practitioneridentifierwith type='NPI'
58Insured's NameClaim.insurance[n].coverage.subscriber->Patient|RelatedPersonnamewhere .focal="true"
59Patient's Relation to the InsuredClaim.insurance[n].coverage.subscriber->Patient|RelatedPersonrelationshipwhere .focal="true"
60Insured's Unique IDClaim.insurance[n].coverageidentifierwhere .focal="true"
61Insured Group NameClaim.insurance[n].coveragegrouping.groupDisplaywhere .focal="true"
62Insured Group NumberClaim.insurance[n].coveragegrouping.groupwhere .focal="true"
63Treatment Authorization CodesClaim.insurance[n].coveragepreAuthRefwhere .focal="true"
64Document Control Number
65Employer NameClaim.insurance[n].coveragepolicyHolder.displayif subscriber is not the policyHolder
66Diagnosis/Procedure Code QualifierClaimdiagnosis[n].codeeableConcept.coding.system
67Principal Diagnosis Code/Other Diagnosis CodesClaimdiagnosis[n].diagnosisCodeableConcept.coding.codewhere diagnosis[n].type = "principal"
68Future Use
69Admitting Diagnosis CodeClaimdiagnosis[n].diagnosisCodeableConcept.coding.codewhere diagnosis[n].type = "admitting"
70Patient's Reason for Visit CodeClaiminformation[n.code and .reason.category='info', .code.coding.system="UB40 information codes, .code.coding.code="visitreason"Claim related or a resource?
71PPS CodeClaiminformation[n].code.category='info', .code.coding.system="UB40 PPS codes"Claim related or a resource?
72External Cause of Injury CodeClaiminformation[n].code.category='info', .code.coding.system="UB40 Cause of Injury codes"Claim related or a resource?
73Future Use
74Principal Procedure/DateClaimdiagnosis[n].procedureCodeableConcept.coding.code
75Future Use
76Attending Name/ID-Qualifier 1GClaim.careTeam[n].provider->Practitionername, identifier
77Operating IDClaiminformation[n].valueString.category='info', .code.coding.system="UB40 information codes, .code.coding.code="operating_id"Claim related or a resource?
78-79Other IDClaiminformation[n].valueString.category='info', .code.coding.system="UB40 information codes, .code.coding.code="operating_id"Claim related or a resource?
80RemarksClaiminformation[n].valueString.category='info', .code.coding.system="UB40 information codes, .code.coding.code="remarks"Claim related.
81Code-Code Field/Qualifiers *0-A0Claiminformation[n].reason=qualifier informatio[n].valueString=attachment control #.category='info', .code.coding.system="UB40 information codes, .code.coding.code="ccfq"Claim related.
*A1-A4
*A5-AB
AC - Attachment Control Number
AD-B0
*B1-B2
*B3
If an NDC code is required along with the service then add the amount for the NDC product to the item.net, add the information element shown below, add an informationLinkId to point to the information element. Alternatively, a GROUP line item may be created with the professional service and the NDC code as details with the costs listed along with the professional service or NDC code appearing in the service code element.
linking id for the informaton elementClaim.information[n].sequence
category of informationClaim.information[n].category = 'info'
NDC codeset urlClaim.information[n].code.coding[1].system
NDC codeClaim.information[n].code.coding[1].code
chargeable amountClaim.information[n].valueQuantity
line item pointer to the informationClaim.item.informationLinkId= .information[n].sequence