(Medicare Claims Processing Manual Crosswalk)

FL49  Unlabeled  1-23  AN  2         FL50  Payer Identification - Primary  A  AN  23   FL50  Payer Identification - Secondary  B  AN  23   FL50  Payer Identification - Tertiary  C  AN  23         FL51  Health Plan Identification Number  A  AN  15   FL51  Health Plan Identification Number  B  AN  15   FL51  Health Plan Identification Number  C  AN  15         FL52  Release of Information - Primary  A  AN  1  1  FL52  Release of Information - Secondary  B  AN  1  1  FL52  Release of Information - Tertiary  C  AN  1  1        FL53  Assignment of Benefits - Primary  A  AN  1  1  FL53  Assignment of Benefits - Secondary  B  AN  1  1  FL53  Assignment of Benefits - Tertiary  C  AN  1  1        FL54  Prior Payments - Primary  A  N  10  1  FL54  Prior Payments - Secondary  B  N  10  1  FL Description  Line  Type  Size Buffer  Space  FL54  Prior Payments - Tertiary  C  N  10  1        FL55  Estimated Amount Due - Primary  A  N  10  1  FL55  Estimated Amount Due - Secondary  B  N  10  1  FL55  Estimated Amount Due - Tertiary  C  N  10  1        FL56  National Provider Identifier (NPI) - Billing Provider  1  AN  15         FL57  Other Provider ID  A  AN  15   FL57  Other Provider ID  B  AN  15   FL57  Other Provider ID  C  AN  15         FL58  Insureds Name - Primary  A  AN  25  1  FL58  Insured's Name - Secondary  B  AN  25  1  FL58  Insured's Name -Tertiary  C  AN  25  1        FL59  Patients Relationship - Primary  A  AN  2  1  FL59  Patient's Relationship - Secondary  B  AN  2  1  FL59  Patient's Relationship - Tertiary  C  AN  2  1        FL60  Insured's Unique ID - Primary  A  AN  20   FL60  Insured's Unique ID - Secondary  B  AN  20   FL60  Insured's Unique ID - Tertiary  C  AN  20         FL61  Insurance Group Name - Primary  A  AN  14  1  FL61  Insurance Group Name - Secondary  B  AN  14  1  FL61  Insurance Group Name -Tertiary  C  AN  14  1        FL62  Insurance Group Number - Primary  A  AN  17  1  FL62  Insurance Group Number - Secondary  B  AN  17  1  FL62  Insurance Group Number - Tertiary  C  AN  17  1        FL63  Treatment Authorization Code - Primary  A  AN  30  1  FL63  Treatment Authorization Code - Secondary  B  AN  30  1  FL63  Treatment Authorization Code - Tertiary  C  AN  30  1        FL64  Document Control Number (DCN)  A  AN  26   FL64  DCN  B  AN  26   FL64  DCN  C  AN  26   FL Description  Line  Type  Size Buffer  Space        FL65  Employer Name (of the insured) - Primary  A  AN  25   FL65  Employer Name (of the insured) - Secondary  B  AN  25   FL65  Employer Name (of the insured) - Tertiary  C  AN  25         FL66  Diagnosis and Procedure Code  Qualifier (ICD Version Indicator)   AN  1         FL67  Principal Diagnosis Code and Present on Admission (POA) Indicator   AN  8         FL67A  Other Diagnosis and POA Indicator   AN  8   FL67B  Other Diagnosis and POA Indicator   AN  8   FL67C  Other Diagnosis and POA Indicator   AN  8   FL67D  Other Diagnosis and POA Indicator   AN  8   FL67E  Other Diagnosis and POA Indicator   AN  8   FL67F  Other Diagnosis and POA Indicator   AN  8   FL67G  Other Diagnosis and POA Indicator   AN  8   FL67H  Other Diagnosis and POA Indicator   AN  8   FL67I  Other Diagnosis and POA Indicator   AN  8   FL67J  Other Diagnosis and POA Indicator   AN  8   FL67K  Other Diagnosis and POA Indicator   AN  8   FL67L  Other Diagnosis and POA Indicator   AN  8   FL67M  Other Diagnosis and POA Indicator   AN  8   FL67N  Other Diagnosis and POA Indicator   AN  8   FL67O  Other Diagnosis and POA Indicator   AN  8   FL67P  Other Diagnosis and POA Indicator   AN  8   FL67Q  Other Diagnosis and POA Indicator   AN  8         FL68  Unlabeled  1  AN  8   FL68  Unlabeled  2  AN  9         L69 Admitting Diagnosis Code   AN  7         FL70a  Patient Reason for Visit Code   AN  7   FL70b  Patient Reason for Visit Code   AN  7   FL70c  Patient Reason for Visit Code   AN  7         FL Description  Line  Type  Size Buffer  Space  FL71  Prospective Payment System (PPS)  Code   AN  3  2        FL72a  External Cause of Injury (ECI) Code and POA Indicator   AN  8   FL72b  ECI Code and POA Indicator   AN  8   FL72c  ECI Code and POA Indicator   AN  8         FL73  Unlabeled   AN  9         FL74  Principal Procedure Code/Date   N/N  7/6  1/1        FL74a  Other Procedure Code/Date   N/N  7/6  1/1  FL74b  Other Procedure Code/Date   N/N  7/6  1/1  FL74c  Other Procedure Code/Date   N/N  7/6  1/1  FL74d  Other Procedure Code/Date   N/N  7/6  1/1  FL74e  Other Procedure Code/Date   N/N  7/6  1/1        FL75  Unlabeled  1  AN  3  1  FL75  Unlabeled  2  AN  4  1  FL75  Unlabeled  3  AN  4  1  FL75  Unlabeled  4  AN  4  1        FL76  Attending Provider - IDs  1  AN  11/2/9   FL76  Attending Provider - Last Name/First Name  2  AN  16/12         FL77  Operating Physician - IDs 1  AN  11/2/9   FL77  Operating Physician - Last Name/First Name  2  AN  16/12         FL78  Other Provider - IDs 1  AN  2/11/2/9   FL78  Other Provider - Last Name/First Name  2  AN  16/12         FL79  Other Provider - IDs 1  AN  2/11/2/9   FL79  Other Provider - Last/First  2  AN  16/12         FL80  Remarks  1  AN  21   FL80  Remarks  2  AN  26   FL80  Remarks  3  AN  26   FL80  Remarks  4  AN  26         FL Description  Line  Type  Size Buffer  Space  FL81  Code -Code -  QUALIFIER/CODE/VALUE  a  AN/AN/AN  2/10/12   FL81  Code -Code -  QUALIFIER/CODE/VALUE  b  AN/AN/AN  2/10/12   FL81  Code -Code -  QUALIFIER/CODE/VALUE  c  AN/AN/AN  2/10/12   FL81  Code -Code -  QUALIFIER/CODE/VALUE  d  AN/AN/AN  2/10/12    75.1 - Form Locators 1- 15 (Rev. 3709, Issued: 02- 03-17; Effective: 04 -04-17; Implementation: 04 -04-17)  Form Locator (FL) 1 -  Billing Provider Name, Address, and Telephone Number   Required.   The minimum entry is the provider name, city, State, and nine -digit ZIP Code.  Phone and/or Fax numbers are desirable.   FL 2 -  Billing Providers Designated Pay- to Name, address, and Secondary Identification Fields   Not Required.   If submitted, the data will be ignored.  FL 3a -  Patient Control Number   Required.   The patients unique alpha -numeric control number assigned by the provider to facilitate retrieval of individual financial records and posting payment may be shown if the provider assigns one and needs it for association and reference purposes.  FL 3b -  Medical/Health Record Number   Situational.  The number assigned to the patients medical/health record by the provider (not FL3a).   FL 4 -  Type of Bill   Required .  This four -digit alphanumeric code gives three specific pieces of information after a leading zero.  CMS will ignore the leading zero.  CMS will continue to process three specific pieces of information.  The second digit identifies the type of facility.  The third classifies the type of care.  The fourth indicates the sequence of this bill in this particular episode of care.  It is referred to as a frequency code.   Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC ( www.nubc.org ) via the NUBCs Official UB -04 Data Specifications Manual.   Code Structure   2nd Digit -Type of Facility (CMS will process this as the 1st digit)   3rd Digit -Bill Classification (Except Clinics and Special Facilities) (CMS will process this as the 2nd digit)   3rd Digit -Classification (Clinics Only) (CMS will process this as the 2nd digit)   3rd Digit -Classification (Special Facilities Only) (CMS will process this as the 2nd digit)  4th Digit -Frequency -  Definition (CMS will process this as the 3rd digit)   FL 5 -  Federal Tax Number  Required.   The format is NN -NNNNNNN.   FL 6 -  Statement Covers Period (From -Through)   Required.   The provider enters the beginning and ending dates of the period included on this bill in numeric fields (MMDDYY).     FL 7   Not Used.   FL 8 -  Patients Name and Identifier   Required.   The provider enters the patients last name, first name, and, if any, middle initial, along with patient identifier (if different than the subscriber/insureds identifier).   FL 9 -  Patients Address   Required.   The provider enters the patients full mailing address, including street number and name, post office box number or RFD, city, State, and ZIP Code.   FL 10 -  Patients Birth Date   Required.   The provider enters the month, day, and year of birth (MMDDCCYY) of patient.  If full birth date is unknown, indicate zeros for all eight digits.  FL 11 -  Patients Sex   Required.   The provider enters an M (male) or an F (female).  The patients sex is recorded at admission, outpatient service, or start of care.   FL 12 -  Admission/Start of Care Date   Required For Inpatient and Home Health.   The hospital enters the date the patient was admitted for inpatient care (MMDDYY).  The HHA enters the same date of admission that was submitted on the RAP for the episode.   FL 13 -  Admission Hour   Not Required.   If submitted, the data will be ignored. FL 14 -  Priority (Type) of Admission or Visit   Required.   Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC ( www.nubc.org ) via the NUBCs Official UB -04 Data Specifications Manual.   FL 15 -  Point of Origin for Admission or Visit   Required except for Bill Type 014X.   The provider enters the code indicating the source of the referral for this admission or visit.