Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.09 - Essential Data Elements for Clean Claims by Hospitals

Current through Register Vol. 51, No. 14, July 12, 2024
A. In General. To qualify as a clean claim, a claim submitted to a third-party payor by a hospital, or person entitled to reimbursement, shall conform to the applicable standard code set and include the following data elements:
(1) Hospital's, or person entitled to reimbursement's, name, address, and telephone number (HCFA Form UB-92, field 1);
(2) Patient's control number (HCFA Form UB-92, field 3);
(3) Type of bill code (HCFA Form UB-92, field 4);
(4) Hospital's, or person entitled to reimbursement's, federal tax ID number (HCFA Form UB-92, field 5);
(5) Beginning and ending date of claim period (HCFA Form UB-92, field 6);
(6) Patient's name (HCFA Form UB-92, field 12);
(7) Patient's address (HCFA Form UB-92, field 13);
(8) Patient's date of birth (HCFA Form UB-92, field 14);
(9) Patient's gender (HCFA Form UB-92, field 15);
(10) Patient's marital status (HCFA Form UB-92, field 16);
(11) Date of admission (HCFA Form UB-92, field 17);
(12) Admission hour (HCFA Form UB-92, field 18);
(13) Type of admission (for example, emergency, urgent, elective, newborn) (HCFA Form UB-92, field 19);
(14) Source of admission code (HCFA Form UB-92, field 20);
(15) Patient-status-at-discharge code (HCFA Form UB-92, field 22);
(16) Medical record number (HCFA Form UB-92, field 23);
(17) Responsible party name and address (HCFA Form UB-92, field 38);
(18) Value code and amounts (HCFA Form UB-92, fields 39-41);
(19) Applicable revenue code (HCFA Form UB-92, field 42) of:
(a) The Health Services Cost Review Commission, for hospitals located in the State, or
(b) The National or State Uniform Billing Data Elements Specifications, for hospitals not located in the State;
(20) Revenue description (HCFA Form UB-92, field 43);
(21) Service date (HCFA Form UB-92, field 45);
(22) Units of service (HCFA Form UB-92, field 46);
(23) Total charge (HCFA Form UB-92, field 47);
(24) Noncovered charges (HCFA Form UB-92, field 48);
(25) Name of the third-party payor (HCFA Form UB-92, field 50);
(26) Provider number (HCFA Form UB-92, field 51);
(27) Release of information (HCFA Form UB-92, field 52);
(28) Assignment of benefits (HCFA Form UB-92, field 53);
(29) Estimated amount due (HCFA Form UB-92, field 55);
(30) Subscriber's name (HCFA Form UB-92, field 58);
(31) Patient's relationship to the subscriber (HCFA Form UB-92, field 59);
(32) Patient's/subscriber's certificate number, health claim number, and ID number (HCFA Form UB-92, field 60);
(33) Treatment authorization code (HCFA Form UB-92, field 63);
(34) Principal diagnosis code (HCFA Form UB-92, field 67);
(35) Admitting diagnosis (HCFA Form UB-92, field 76);
(36) Attending physician ID (HCFA Form UB-92, field 82);
(37) Other physician ID (HCFA Form UB-92, field 83);
(38) Signature of the provider representative or notation that the signature is on file with the third-party payor (HCFA Form UB-92, field 85);
(39) Date the bill was submitted (HCFA Form UB-92, field 86); and
(40) Any other field or essential data element necessary to comply with the applicable standard code set.