Billing facility claims

Send facility claims to Priority Health by completing the standard UB04 form.

• Hand-written claims will not be accepted
• A valid CPT/HCPCS code must be included when billing any of the revenue codes on this list. Claims with these revenue codes that do not have the CPT/HCPCS code will be denied.
  
• A POA indicator is required on all inpatient claims. 
  
• Itemizations are required when you bill us for rehabilitation services
• Do not use highlighters
• Send your completed form to our Claims addresses
  

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
Filed 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
Filed 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