If the UB Payer check box is selected for the primary carrier in the Ins field at the top of the Procedure Entry screen and/or the UB Billing check box is selected in the Location Code Table for the Location selected, this attachment will be triggered.
| Prompt | Response | Req | Len |
|---|---|---|---|
| Type of Bill Box 4 | Enter the type of bill. | 50 | |
| Admission Date Box 6A and 12 | Enter the date you want or click the calendar icon to select a date. | 10 | |
| Discharge Date Box 6B | Enter the date you want or click the calendar icon to select a date. | 10 | |
| Admission Hour Box 13 | Enter the Admission Hour. | 50 | |
| Admission Type Box 14 | Enter the Admission Type. | 50 | |
| Admission Src Box 15 | Enter the Admission Src. | 50 | |
| Discharge Hour Box 16 | Enter the Discharge Hour. | 50 | |
| Discharge Status Box 17 | Enter the Discharge Status. | 50 | |
| Condition Code Box 18 to Box 28 | Enter the Condition Code(s). | 50 | |
| ACDT State Box 29 | Enter the ACDT State. | 50 | |
| Local Use Box 30 | 50 | ||
| Occurrence Code Box 31A to Box 34B | Enter the Occurrence Code(s). | 50 | |
| Occurrence Date Box 31A to Box 34B | Enter the date you want or click the calendar icon to select a date. | 10 | |
| Occurrence Span Code Box 35A to Box 36B | Enter the Occurrence Span Code(s). | 50 | |
| Occurrence Span Start Date Box 35A to Box 36B | Enter the Occurrence Span Start Date(s) you want or click the calendar icon to select a date. | 10 | |
| Occurrence Span End Date Box 35B to Box 36B | Enter the Occurrence Span End Date(s) you want or click the calendar icon to select a date. | 10 | |
| Local Use Box 37A and Box 37B | 50 | ||
| Value Code Box 39A to Box 41D | Enter the Value Code(s). | 50 | |
| Value Amount Box 39A to Box 41D | Enter the Value Amounts(s). | 50 | |
| Authorization Box 63A to Box 63C | Enter the Authorization(s). | 50 | |
| Document Control Box 64A to Box 64C | Enter the Document Control(s). | 50 | |
| Admit Diagnosis Code Box 69 | Enter the code(s) you want or click the magnifying glass to search the table. | 1 | |
| Patient Reason Dx Box 70A to Box 70C | Enter the code(s) you want or click the magnifying glass to search the table. | 1 | |
| PPS Code Box 71 | Enter the PPS Code. | 1 | |
| External Cause of Injury Box 72B to Box 72C | Enter the code(s) you want or click the magnifying glass to search the table. | 1 | |
| Local Use Box 73 | 50 | ||
| Principal Procedure Code Box 74 | Enter the Principal Procedure Code. | 50 | |
| Principal Procedure Date Box 74 | Enter the date you want or click the calendar icon to select a date. | 10 | |
| Other Procedure Code Box 74A to Box 74E | Enter any Other Procedure Code(s). | 50 | |
| Other Procedure Date Box 74A to Box 74E | Enter any Other Procedure Date(s) you want or click the calendar icon to select a date. | 10 | |
| Remarks Box 80A to Box 80C | Enter any Remark(s). | 50 | |
| Local Use Box 81 CCA to Box 81 CCD | 50 |
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