UB-92 Claim Forms

BlueAdvantage Administrators of Arkansas scans paper claims for processing electronically. The following tips will help prevent UB-92 claims from being delayed or rejected:

• All data must be contained within its defined area.
• All dollar fields should be blank or have real values.
• Zeros are of no value, and they are invalid to OCR (optical character recognition).
• Do not handwrite or put comments on claims.

The electronic scanning process has also allowed us to process UB-92 claims through edits on the front end before they enter the claim system. The most common errors are:

• No Source of Admission Code in Form Locator 20
• No Patient Status Code in Form Locator 22
• No Provider Number in Form Locator 51

The UB-92 manual available from the Arkansas Hospital Association is our guide for completing this form.

Instructions for Completing the UB-92

DATES: Boxes 6, 14, 17, 32-36, 45, 80, 81. All date fields except Box 14 should be filled out as MMDDYY. Do not use slashes, hyphens or spaces to separate month, day or year. Always put a zero in front of single-digit days or months. Box 14 (birthday) should have 4-digit year.

B0X 1: Provider name and address. Do not type information above Box 1. Always place phone number as last line in this box. Format expected is Line 1, provider name; Line 2, provider street; Line 3, provider city, state, zip (5 or 9 positions); Line 4, provider phone (7 or 10 positions).

BOX 3: Patient control number. Should start on left side of box. Number next to bill type can become part of bill type.

BOX 12: Patient name. Enter last, first and initial. No commas, periods or titles.

BOX 13: Patient address. Enter street, city, state, zip (5 or 9). Do not use separators such as semi-colons; use spaces.

BOX 38: Insured name and address. First line is for name (last, first and initial). No periods, commas or titles. Line 2: Address one contains street or apartment number, etc. Line 3: Can be a second street, box, etc. Line 4: City, state and zip (5 or 9). Do not enter phone numbers because they distort OCR, and there is no place to store them on the NSF records.

BOX 46: Enter whole numbers only. Fractions and decimals are not allowed.

BOX 50: Enter payer left-justified; try to stay away from Box 51.

BOX 51: Provider number; please left-justify.

BOX 58: Insured name: Enter last, first, middle initial. Do not use periods, commas or titles.

BOX 66: Employer location: Format is street, city, state, zip.

BOXES 67- 80: Codes and dates must be in their allocated space. Space is tight and can easily flow to the next box.

BOX 82: Attending physician ID should be entered on the first line only; do not put on second line. Physician name should be entered on the second line as last, first, initial. No periods, commas or titles.

BOX 83: A and B allow for two entries of other physicians. Use the same rules as Box 82. Enter ID on Line 1 only and name on Line 2. Name format is last, first, initial. No commas, periods or titles.

Adhering to these rules will greatly improve the quality of the data the scanning process attempts to interpret.

For More Information

Please contact your network development representative.