In order to comply with Department of Health Care Services (DHCS) requirements, inpatient claims must only bill for services dated within the statement date. Codes dated prior to or after the statement date are billing incorrectly.
Codes that need to fall on or within the statement dates include: occurrence, principle procedure and other procedure. If the date of any code billed does not fall between the statement period dates, the claim is incorrectly completed. See correct hardcopy UB-04 claim form examples below.
UB-04 Hardcopy, Field 6: Statement Covers Period
Enter the beginning and ending service dates of the entire period covered in the claim in MMDDYY format. For services provided on a single day, enter the date of service as both the “from” and “through” date. Any other codes submitted on the claim need to fall on or within the statement covers period dates.
Electronic submission: 837I Loop 2300, Segment DTP with qualifier 434.
UB-04 Hardcopy, Fields 12-13: Admission / Start of Care Date and Admission Hour
Enter the date of admission for inpatient services. Enter in MMDDYY format. The day on which the patient is formally admitted as an inpatient is counted as the first inpatient day; this should not be altered.
Enter the admit hour as follows: Eliminate the minutes and convert the hour of admission/discharge to 24-hour (00 – 23) format (for example, 3 p.m. = 15)
Electronic submission: 837I Loop 2300, Segment DTP with qualifier 435.
UB-04 Hardcopy, Fields 31-34: Occurrence Codes and Dates
Enter the code and associated date noting a significant event relating to the claim that may affect payer processing.
UB-04 Hardcopy, Fields 35-36: Occurrence Span Codes and Dates
Enter the code and the related dates that identify an event relating to the payment of the claim.
UB-04 Hardcopy, Field 74: Principal Procedure Code and Date
The ICD-10-CM code for the principal procedure and date performed.
UB-04 Hardcopy, Fields 74a – 74e: Other Procedure Codes and Dates
Enter the ICD-10-CM procedure codes and dates for up to 5 additional procedures.
If you have any questions or need more information, please contact the Alliance Claims department at (800) 700-3874, ext. 5503.
