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.

Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.

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

Indicates that the Performing Provider has a contract with the Payer as of the effective date of service or admission.

NCPDP value indicating the number fill of the current dispensed supply (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.