HIPAA Reference ASC X12N/005010A1 UB-04 Transaction Set/Loop/ Form Segment ID/Code Value/ Data Element # Data Element Name Locator Reference Designator IP4001 Record Type NA NA IP4002 Sequence Number NA NA IP4003 Patient Control Number 3A 837/2300/CLM/01 IP4004 Type of Bill 4 837/2300/CLM/05-1 837/2300/CLM/05-3 HIPAA Reference ASC X12N/005010A1 UB-04 Transaction Set/Loop/ Form Segment ID/Code Value/ Data Element # Data Element Name Locator Reference Designator IP5001 Record Type NA NA IP5002 Sequence Number NA NA IP5003 Patient Control Number 3A 837/2300/CLM/01 IP5004 Accommodations Revenue Code - 1 42 837/2400/SV2/01 IP5005 Accommodations Service Units - 1 46 837/2400/SV2/DA/05 IP5006 Accommodations Total Charges - 1 47 837/2400/SV2/03 IP5007 Accommodations Revenue Code - 2 42 837/2400/SV2/01 IP5008 Accommodations Service Units - 2 46 837/2400/SV2/DA/05 IP5009 Accommodations Total Charges - 2 47 837/2400/SV2/03 IP5010 Accommodations Revenue Code - 3 42 837/2400/SV2/01 IP5011 Accommodations Service Units - 3 46 837/2400/SV2/DA/05 IP5012 Accommodations Total Charges - 3 47 837/2400/SV2/03
Data Element # Data Element Name UB-04 Form Locator HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator IP4001 Record Type NA NA IP4002 Sequence Number NA NA IP4003 Patient Control Number 3A 837/2300/CLM/01 IP4004 Type of Bill 4 837/2300/CLM/05-1 837/2300/CLM/05-3 Data Element # Data Element Name UB-04 Form Locator HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator IP5001 Record Type NA NA IP5002 Sequence Number NA NA IP5003 Patient Control Number 3A 837/2300/CLM/01 IP5004 Accommodations Revenue Code - 1 42 837/2400/SV2/01 IP5005 Accommodations Service Units - 1 46 837/2400/SV2/DA/05 IP5006 Accommodations Total Charges - 1 47 837/2400/SV2/03 IP5007 Accommodations Revenue Code - 2 42 837/2400/SV2/01 IP5008 Accommodations Service Units - 2 46 837/2400/SV2/DA/05 IP5009 Accommodations Total Charges - 2 47 837/2400/SV2/03 IP5010 Accommodations Revenue Code - 3 42 837/2400/SV2/01 IP5011 Accommodations Service Units - 3 46 837/2400/SV2/DA/05 IP5012 Accommodations Total Charges - 3 47 837/2400/SV2/03
Chapter%20241_20170907_v2.docx