New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-C - Commissioner, Department of Health and Human Services
Chapter He-C 1500 - DATA SUBMISSION AND RELEASE OF HEALTH CARE FACILITY DISCHARGE DATA
Part He-C 1503 - HEALTH CARE FACILITY DISCHARGE DATA SET SUBMISSION REQUIREMENTS
Section He-C 1503.04 - Required Data Elements
Universal Citation: NH Admin Rules He-C 1503.04
Current through Register No. 40, October 3, 2024
(a) The following elements from the UB-04 reporting standard shall be submitted as follows:
(1) UB-04 Form Locator 01, "billing provider
name, address and telephone number";
(2) UB-04 Form Locator 02, "pay-to name and
address";
(3) UB-04 Form Locator
03a, "patient control number";
(4)
UB-04 Form Locator 03b, "medical/health record number", which shall be required
on all claims;
(5) UB-04 Form
Locator 04, "type of bill";
(6)
UB-04 Form Locator 05, "federal tax ID number";
(7) UB-04 Form Locator 06, "statement covers
period";
(8) UB-04 Form Locator 08,
"patient name/identifier", which shall:
a. Be
encrypted using a standard methodology and software provided by the department
or its agent before submission to the department or its agent; and
b. Be divided into 4 distinct components of
patient last name, patient first name, patient middle name, and patient
generational identifier suffix, all provided in upper case prior to
encryption;
(9) UB-04
Form Locator 09, "patient address";
(10) UB-04 Form Locator 10, "patient birth
date";
(11) UB-04 Form Locator 11,
"patient sex";
(12) UB-04 Form
Locator 12, "admission/start of care date", which shall be required on all
claims;
(13) UB-04 Form Locator 13,
"admission hour", which shall be required on all claims;
(14) UB-04 Form Locator 14, "priority (type)
of visit";
(15) UB-04 Form Locator
15, "point of origin for admission or visit";
(16) UB-04 Form Locator 16, "discharge hour",
which shall be required on all inpatient and observation stay claims;
(17) UB-04 Form Locator 17, "patient
discharge status";
(18) UB-04 Form
Locator 18 through 28, "condition codes", which shall:
a. Be submitted as recorded; and
b. Be collected, recorded, and submitted
where applicable for:
1. 02 = Condition is
Employment-Related; and
2. P1 = Do
Not Resuscitate Order (DNR);
(19) UB-04 Form Locator 31 through 34,
"occurrence codes and dates 1 - 4", which shall:
a. Be submitted as recorded; and
b. Be collected, recorded, and submitted
where applicable for 04 = Accident/employment related date;
(20) UB-04 Form Locator 39 through
41, "value codes and amounts", which shall:
a. Be submitted as recorded; and
b. Be collected, recorded, and submitted
where applicable for:
1. 54 = Newborn Birth
Weight in Grams; and
2. P0 = For
newborns, mother's medical record number;
(21) UB-04 Form Locator 42, "revenue
code";
(22) UB-04 Form Locator 44,
"HCPCS or CPT/accommodation rates/HIPPS rate codes", except the length limit
shall not apply;
(23) UB-04 Form
Locator 45, "service date";
(24)
UB-04 Form Locator 46, "service units";
(25) UB-04 Form Locator 47, "total
charges";
(26) UB-04 Form Locator
50, "payer name", except the length limit shall not apply;
(27) UB-04 Form Locator 51, "health plan
identification number";
(28) UB-04
Form Locator 56, "national provider identifier - billing provider";
(29) UB-04 Form Locator 57, "other (billing)
provider identifier";
(30) UB-04
Form Locator 59, "patient's relationship to insured";
(31) UB-04 Form Locator 64, "document control
number";
(32) UB-04 Form Locator
65, "employer", which shall:
a. When the
employer is not known, be recorded as "UNKNOWN"; and
b. When not employed, be recorded as
"NA.";
(33) UB-04 Form
Locator 66, "diagnosis and procedure code qualifier";
(34) UB-04 Form Locator 67, "principal
diagnosis code and present on admission indicator" which for the present on
admission (POA) element shall only be recorded on inpatient acute care
discharges;
(35) UB-04 Form Locator
67A-Q, "other diagnosis codes and present on admission indicator" which for the
POA element shall only be recorded on inpatient acute care
discharges;
(36) UB-04 Form Locator
69, "admitting diagnosis code";
(37) UB-04 Form Locator 70A-C, "patient's
reason for visit";
(38) UB-04 Form
Locator 72A-C, "external cause of injury code (ECI) and present on admission
indicator", which shall be reported in order for every applicable principal and
other diagnoses;
(39) UB-04 Form
Locator 74, "principal procedure code and date";
(40) UB-04 Form Locator 74A-E, "other
procedure codes and dates";
(41)
UB-04 Form Locator 76, "attending provider name and identifiers";
(42) UB-04 Form Locator 77, "operating
physician name and identifiers";
(43) UB-04 Form Locator 78 and 79, "other
provider (individual) names and identifiers";
(44) UB-04 Form Locator 80, "remarks";
and
(45) UB-04 Form Locator 81A-D,
"code-code field", which shall:
a. Be
submitted as recorded; and
b. Be
collected, recorded, and submitted where applicable for B1 (race and ethnicity)
.
(b) The health care facility shall submit information regarding primary language spoken as an integer numeric element which health care facilities shall code consistently.
# 9436, eff 3-21-09
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