Form Locators 1-15

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 Provider’s 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 patient’s 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 patient’s 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 NUBC’s 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 - Patient’s Name and Identifier Required. The provider enters the patient’s last name, first name, and, if any, middle initial, along with patient identifier (if different than the subscriber/insured’s identifier). FL 9 - Patient’s Address Required. The provider enters the patient’s full mailing address, including street number and name, post office box number or RFD, city, State, and ZIP Code. FL 10 - Patient’s 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 - Patient’s Sex Required. The provider enters an “M” (male) or an “F” (female). The patient’s 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 NUBC’s 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. Codes used for Medicare claims are available from Medicare contractors. Codes are also available from the NUBC (www.nubc.org) via the NUBC’s Official UB-04 Data Specifications Manual.