evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
CR#  R299CP  09/10/2004  Use of Condition Code 44, "Inpatient Admission Changed to Outpatient"  10/12/2004  3444  R296CP  09/03/2004  Payment Denial for Medicare Services Furnished to Alien Beneficiaries Who Are Not Lawfully Present in the United States  N/A 2825  R282CP  08/20/2004  Good Cause Waiver of Late Claim Filing Payment Reduction Penalty  09/14/2004  3402  R274CP  08/13/2004  Good Cause Waiver of Late Claim Filing Payment Reduction Penalty  09/14/2004  3042  R273CP  08/13/2004  Modification of CMS's Medicare Contingency Plan for HIPAA Implementation  07/06/2004  2981  R270CP  08/03/2004  Update to the Frequency of Billing  01/03/2005  3382  R239CP  07/23/2004  Update to the Frequency of Billing  01/03/2005  3382  R213CP  06/25/2004  Payment to Bank in the Name of a Provider/Physician/Supplier  07/25/2004  3079  R211CP  06/18/2004  Elimination of Regulations for Written Statement of Intent (SOI)  07/19/2004  3310  R207CP  06/18/2004  Expansion of Policy Where Patient is a Member of a Medicare Advantage (MA) Organization For Only a Portion of the Billing Period to Include Inpatient Rehabilitation Facilities (IRF) and Long Term Care Hospitals (LTCH)  07/19/2004  3309  R196CP  06/04/2004  Payment Denial for Medicare Services Furnished to Alien Beneficiaries Who Are Not Lawfully Present in the U. S.  N/A 2825  R170CP  05/07/2004  Filing Request for Payment -Medicare Part B  N/A 2815  R169CP  05/07/2004  Claims Jurisdiction  N/A 2631  R167CP  04/30/2004  Discontinued Use of Revenue Code 0910  10/04/2004  3194  R156CP  04/30/2004  Clarification of payments and billing procedures for hospitals subject to the Maryland Waiver  10/04/2004  3200  R145CP  04/23/2004  Data Element Requirements Matrix - Carrier  05/24/2004  3164  R142CP  04/16/2004  Claims for RRB and UMWA Beneficiaries  N/A 2502  R133CP
(Medicare Claims Processing Manual)
04/23/2004  Data Element Requirements Matrix - Carrier  05/24/2004  3164  R142CP  04/16/2004  Claims for RRB and UMWA Beneficiaries  N/A 2502  R133CP  04/02/2004  Billing Non -covered Charges to FIs -Clarification to CR 2634  04/16/2004  3115  R114CP  02/27/2004  Modification of CMS' Medicare Contingency Plan for HIPPA Implementation  07/06/2004  2981  R111CP  02/27/2004  Payment For Services Provided Under a Contractual Agreement  03/12/2004  3083  R091CP  02/06/2004  Revisions to Processing of Non -covered Charges on Certain Home Health Prospective Payment System Claims  07/06/2004  3077  Rev #  Issue Date  Subject  Impl Date  CR#  R072CP  01/23/2004  Update of Address for the Railroad Retirement Board (RRB)  02/23/2004  3034  R067CP  01/16/2004  Claims Processing Instructions for Payment Jurisdiction and Payment to Physician for Purchased Diagnostic Tests  04/05/2004  3039  R047CP  12/19/2003  Carrier Data Element Requirements  01/20/2004  2956  R025CP  10/31/2003 Billing Non -Covered Charges to Fiscal Intermediaries Summary and New Instruction  04/05/2004  2634  R001CP  10/01/2003  Initial Publication of Manual  NA NA Back to top of Chapter
(Medicare Claims Processing Manual Crosswalk)
Medicare Claims Processing Manual  Chapter 25 - Completing and Processing the Form CMS -1450 Data Set   Table of Contents  (Rev. 12423, 12- 20-23)  Transmittals for Chapter 25  10 - Reserved  70 - Uniform Bill -  Form CMS -1450 70.1 -  Uniform Billing with Form CMS -1450 70.2 -  Disposition of Copies of Completed Forms  75 - General Instructions for Completion of Form CMS -1450 for Billing  75.1 -  Form Locators 1 -15 75.2 -  Form Locators 16- 30  75.3 -  Form Locators 31- 41 75.4 -  Form Locator 42  75.5 -  Form Locators43- 65 75.6  Form Locators 66 -81 80 - Reserved  10 - Reserved   70 - Uniform Bill - Form CMS -1450 (Rev. 2874, Issued: 02- 06-14, Effective: 03 -07-14, Implementation: 03- 07-14)  70.1 - Uniform Billing with Form CMS -1450 (Rev. 2922, Issued: 04- 03-14, Effective: 04 -18-14, Implementation: 04- 18-14)  This form, also known as the UB -04, is a uniform institutional provider bill suitable for use in billing multiple third party payers.  Because it serves many payers, a particular payer may not need some data elements.  The National Uniform Billing Committe e (NUBC) maintains lists of approved coding for the form.  Medicare Administrative Contractors servicing both Part A and Part B lines of business (A/B MACs (A) and (HHH)) responsible for receiving institutional claims also maintain lists of codes used by Medicare.  All items on Form CMS -1450 are described.  The A/B MAC (A) or (HHH) must be able to capture all NUBC -approved input data described in section 75 for audit trail purposes and be able to pass coordination of benefits data to other payers with whom it has a coordination of benefits agreement.   70.2 - Disposition of Copies of Completed Forms (Rev. 2922, Issued: 04- 03-14, Effective: 04 -18-14, Implementation: 04- 18-14)
(Medicare Claims Processing Manual Crosswalk)
70.2 - Disposition of Copies of Completed Forms (Rev. 2922, Issued: 04- 03-14, Effective: 04 -18-14, Implementation: 04- 18-14)  The provider retains the copy designated Institution Copy and submits the remaining copies of the completed Form CMS -1450 to its A/B MAC (A) or (HHH), managed care plan, or other insurer.  Where it knows that a managed care plan will pay the bill, it sends the bill and any necessary supporting documentation directly to the managed care plan for coverage determination, payment, and/or denial action.  It sends to the A/B MAC (A) or (HHH) bills that it knows will be paid and processed by the A/B MAC (A) or ( HHH).   75 - General Instructions for Completion of Form CMS -1450 for Billing (Rev. 2922, Issued: 04- 03-14, Effective: 04 -18-14, Implementation: 04- 18-14)  This section contains Medicare requirements for use of codes maintained by the NUBC that are needed in completion of the Form CMS -1450 and compliant Accredited Standards Committee (ASC) X12 837 institutional claims.  Note that the internal claim record used for processing is not being expanded.  Instructions for completion are the same for inpatient and outpatient claims unless otherwise noted.  The A/B MAC (A) or (HHH) does not need to search paper files to annotate missing data unless it does not have an electronic history record.  It does not need to obtain data that is not needed to process the claim.   Effective June 5, 2000, CMS extended the claim size to 450 lines.  For the Form CMS -1450, this simply means that the A/B MAC (A) or (HHH) accepts claims of up to 9 pages.  The following layout describes the data specifications Form CMS -1450.    FORM CMS -1450 LAYOUT SUMMARY   FL Description  Line  Type  Size Buffer  Space  FL01  [Billing Provider Name]  1  AN  25   FL01  [Billing Provider Street Address]  2  AN  25   FL01  [Billing Provider City, State, Zip]  3  AN  25   FL01  [Billing Provider Telephone, Fax, Country Code]  4  AN  25
(Medicare Claims Processing Manual Crosswalk)
FL02  [Billing Providers Designated Pay -to Name]  1  AN  25   FL02  [Billing Providers Designated Pay -to Address]  2  AN  25   FL02  [Billing Providers Designated Pay -to City, State]  3  AN  25   FL02  [Billing Providers Designated Pay -to ID]  4  AN  25         FL03a  Patient Control Number   AN  24   FL03b  Medical/Health Record Number   AN  24         FL04  Type of Bill  1  AN  4  1        FL05  Federal Tax Number  1  AN  4   FL05  Federal Tax Number  2  AN  10         FL06  Statement Covers Period - From/Through  1  N/N  6/6  1/1        FL07  Unlabeled  1  AN  7   FL07  Unlabeled  2  AN  8         FL08  Patient Name and Identifier (ID)  1a  AN  19   FL08  Patient Name  2b  AN  29         FL09  Patient Address - Street  1a  AN  40  1  FL09  Patient Address - City  2b  AN  30  2  FL09  Patient Address - State  2c  AN  2  1  FL09  Patient Address - ZIP  2d  AN  9  1  FL09  Patient Address - Country Code  2e  AN  3         FL10  Patient Birthdate  1  N  8  1        FL Description  Line  Type  Size Buffer  Space  FL11  Patient Sex  1  AN  1  2        FL12  Admission/Start of Care Date  1  N  6         FL13  Admission Hour  1  AN  2  1        FL14  Priority (Type) of Admission or Visit  1  AN  1  2        FL15  Point of Origin for Admission or Visit  1  AN  1  2        FL16  Discharge Hour  1  AN  2  1        FL17  Patient Discharge Status   1  AN  2  1        FL18  Condition Code   AN  2  1  FL19  Condition Code   AN  2  1  FL20  Condition Code   AN  2  1  FL21  Condition Code   AN  2  1  FL22  Condition Code   AN  2  1  FL23  Condition Code   AN  2  1  FL24  Condition Code   AN  2  1  FL25  Condition Code   AN  2  1  FL26  Condition Code   AN  2  1  FL27  Condition Code   AN  2  1  FL28  Condition Code   AN  2  1        FL29  Accident State   AN  2  1        FL30  Unlabeled  1  AN  12   FL30  Unlabeled  2  AN  13         FL31  Occurrence Code/Date  a  AN/N  2/6  1/1  FL31  Occurrence Code/Date  b  AN/N  2/6  1/1        FL32  Occurrence Code/Date  a  AN/N  2/6  1/1  FL32  Occurrence Code/Date  b  AN/N  2/6  1/1
(Medicare Claims Processing Manual Crosswalk)
FL32  Occurrence Code/Date  a  AN/N  2/6  1/1  FL32  Occurrence Code/Date  b  AN/N  2/6  1/1        FL33  Occurrence Code/Date  a  AN/N  2/6  1/1  FL33  Occurrence Code/Date  b  AN/N  2/6  1/1        FL Description  Line  Type  Size Buffer  Space  FL34  Occurrence Code/Date  a  AN/N  2/6  1/1  FL34  Occurrence Code/Date  b  AN/N  2/6  1/1        FL35  Occurrence Span Code/From/Through  a  AN/N/N  2/6/6  1/1/1  FL35  Occurrence Span Code/From/Through  b  AN/N/N  2/6/6  1/1/1        FL36  Occurrence Span Code/From/Through  a  AN/N/N  2/6/6  1/1/1  FL36  Occurrence Span Code/From/Through  b  AN/N/N  2/6/6  1/1/1        FL37  Unlabeled  a  AN  8   FL37  Unlabeled  b  AN  8         FL38  Responsible Party Name/Address  1  AN  40  2  FL38  Responsible Party Name/Address  2  AN  40  2  FL38  Responsible Party Name/Address  3  AN  40  2  FL38  Responsible Party Name/Address  4  AN  40  2  FL38  Responsible Party Name/Address  5  AN  40  2        FL39  Value Code  a  AN  2  1  FL39  Value Code Amount  a  N  9  1  FL39  Value Code  b  AN  2  1  FL39  Value Code Amount  b  N  9  1  FL39  Value Code  c  AN  2  1  FL39  Value Code Amount  c  N  9  1  FL39  Value Code  d  AN  2  1  FL39  Value Code Amount  d  N  9  1        FL40  Value Code  a  AN  2  1  FL40  Value Code Amount  a  N  9  1  FL40  Value Code  b  AN  2  1  FL40  Value Code Amount  b  N  9  1  FL40  Value Code  c  AN  2  1  FL40  Value Code Amount  c  N  9  1  FL40  Value Code  d  AN  2  1  FL40  Value Code Amount  d  N  9  1        FL41  Value Code  a  AN  2  1  FL41  Value Code Amount  a  N  9  1  FL41  Value Code  b  AN  2  1  FL41  Value Code Amount  b  N  9  1  FL Description  Line  Type  Size Buffer  Space  FL41  Value Code  c  AN  2  1  FL41  Value Code Amount  c  N  9  1  FL41  Value Code  d  AN  2  1  FL41  Value Code Amount  d  N  9  1
(Medicare Claims Processing Manual Crosswalk)
FL42  Revenue Codes  1-23  N  4   FL43  Revenue Code Description/IDE Number/Medicaid Drug rebate  1-23  AN  24   FL44  HCPCS/Accommodation Rates/HIPPS Rate Codes  1-23  N  14   FL45  Service Dates  1-23  N  6   FL46  Service Units  1-23  N  7   FL47  Total Charges  1-23  N  9   FL48  Non-Covered Charges  1-23  N  9         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
(Medicare Claims Processing Manual Crosswalk)
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
(Medicare Claims Processing Manual Crosswalk)
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
(Medicare Claims Processing Manual Crosswalk)
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)
(Medicare Claims Processing Manual Crosswalk)
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
(Medicare Claims Processing Manual Crosswalk)
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.   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.   75.2 - Form Locators 16 -30 (Rev. 1973, Issued: 05- 21-10, Effective: 09 -01-10, Implementation: 09- 01-10)  FL 16 -  Discharge Hour   Not Required .  FL 17  - Patient Discharge Status    Required .  (For all Part A inpatient, SNF, hospice, home health agency (HHA) and outpatient hospital services.)  This code indicates the patients discharge status as of the Through date of the billing period (FL 6).   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.   FLs 18 -  28 - Condition Codes   Situational .  The provider enters the corresponding code (in numerical order) to describe any of the following conditions or events that apply to this billing period.  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 29 -  Accident State  Not used.  Data entered will be ignored. FL 30 -  (Untitled)  Not used.  Data entered will be ignored.  75.3 - Form Locators 31 -41 (Rev. 2922, Issued: 04- 03-14, Effective: 04 -18-14, Implementation: 04- 18-14)  FLs 31, 32, 33, and 34 -  Occurrence Codes and Dates   Situational .  Required when there is a condition code that applies to this claim.