Dates corresponding with the admission and discharge of the beneficiary to a facility

UB-04 Source of Admission (FL-15) identifies the place where the patient was identified as needing admission to a facility.

UB-04 Priority of the admission (FL-14) indicates, for example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled.

NCPDP code indicating whether the plan adjudicated the claim as a brand or generic drug.

Date the claim was received by the payer.

NCPDP code indicating whether or not the prescription is a compound.

NCPDP code indicating the prescriber's instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication.

NCPDP value indicating the Number of days supply of medication dispensed by the pharmacy.

UB-04 Discharge Status (FL-17) indicates the patient’s status as of the discharge date for a facility stay.

DRG (Diagnosis Related Group), including the code system, the DRG version and the code value

NCPDP value indicating the number fill of the current dispensed supply (0, 1, 2, etc.)

NCPDP value indicating the number of refills authorized by the subscriber (0, 1, 2, etc.)

NCPDP code indicating whether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy.

The facility where the service occurred. Examples include hospitals, nursing homes, laboratories or homeless shelters.

UB-04 Type of Bill (FL-04) provides specific information for payer purposes.

Patient Medical Record Number associated with the specific claim.

Patient Account Number associated with the specific claim.

Orthodontics treatment indicator.

Prosthesis replacement indicator.

Additional tooth number or oral cavity. Additional body sites are specific to line item and have to be linked by ExplanationOfBenefit.item.informationSequence.

Missing tooth number.

Patient weight (for transportation services)

Reason ambulance transport was needed (for transportation services)

Distance traveled (for transportation services)

Reason for round trip (for transportation services)

Purpose of using a stretcher (for transportation services)

Patient pick-up Location (for transportation services)

Patient drop-off location (for transportation services)