Billing facility claims
Send facility claims to Priority Health by completing the standard UB04 form.
| UB04 fields |
| Field 1 |
Provider name and address |
| Field 2 | Pay-to location |
| Field 3A |
Patient control number |
| Field 3B |
Medical health record number |
| Field 4 |
Type of bill |
| Field 5 |
Federal tax identification number |
| Filed 6 |
Statement covers period |
| Field 8 |
Patient name-ID number |
| Field 9 |
Patient address |
| Field 10 |
Patient birthdate |
| Field 11 |
Patient sex |
| Field 12 |
Admission date |
| Field 13 |
Admission hour |
| Field 14 |
Type of admission |
| Field 15 |
Source of admission |
| Field 17 |
Patient status |
| Field 18-28 |
Condition codes |
| Field 31-36 |
Occurrence codes |
| Field 38 |
Responsible party name and address |
| Field 39-41 |
Value codes (if applicable) |
| Field 42 |
Revenue code |
| Field 43 |
Description of revenue code |
| Field 44 |
HCPCS rates (CPT codes required if billing for lab, diagnostic or therapeutic procedures) |
| Field 45 |
Service date |
| Field 46 |
Service units (if applicable) |
| Field 47 |
Total charges (by revenue code category) |
| Field 48 |
Non-covered charges - primary payer (if applicable) |
| Field 50 |
Payer name |
| Field 51 |
Health plan ID (provider number) |
| Field 52 |
Release of information |
| Field 53 |
Assignment of benefits |
| Field 54 |
Prior payments (if applicable) |
| Field 55 |
Estimated amount due |
| Field 56 |
National provider identification (NPI) |
| Field 57 |
Other/payer identification |
| Field 58 |
Insured's name |
| Field 59 |
Patient's relationship to insured |
| Field 60 |
Policy holder's contract number |
| Field 61 |
Group name |
| Field 62 |
Group number |
| Field 66 |
Internal classification of disease (ICD) version qualifier (ICD-9) |
| Field 67A-Q |
Principal diagnosis; also see POA indicators |
| Field 69 |
Admitting diagnosis |
| Field 70 |
Patient reason for visit (DX) |
| Field 71 |
Prospective payment system (PPS) code |
| Field 72 |
External cause of injury |
| Field 73 |
DRG (inpatient only) |
| Field 76 |
NPI for attending physician |
| Field 77 |
NPI for operating physician |
| Field 78 |
NPI for the other physician |
