HMS, 1500, and UB-04 Field Names

Patient Fields                      
HMS Field Name 1500 Field Name UB-04 Field Name
17 PAT-LAST-NAME 2 Patient's Name 8 Patient Name
18 PAT-FIRST-NAME 2 Patient's Name 8 Patient Name
19 PAT-MID-INIT 2 Patient's Name 8 Patient Name
20 PAT-SEX 3 Patient's Birth Date and Sex 11 Sex
21 PAT-DOB-CCYYMMDD 3 Patient's Birth Date and Sex 10 Birthdate

 

Provider Fields                       
HMS Field Name 1500 Field Name UB-04 Field Name
3 SERVICING-PROV-NUMBER 25 Federal Tax ID Number  
4 SERVICING-PROV-NPI 24j Rendering Provider ID #  
63 PAY-TO-PROVIDER-NUMBER 33b (no name)  
64 PAY-TO-PROVIDER-NPI 33a (no name) 5 Fed Tax No.
65 REFERRING-PROVIDER-NUMBER 17a (no name)  
66 REFERRING-PROVIDER-NPI 17b (no name)  

 

Service Fields                   
HMS Field Name 1500 Field Name UB-04 Field Name
8 PAT-STATUS-CODE   17 Stat
35 TPL-ACCIDENT-INDICATOR 10 Is Patient's Condition Related To?  
36 PRIMARY-DIAG 21.1 Diagnosis or Nature of Illness or Injury 70 Patient Reason Dx
37 ADMITTING-DIAGNOSIS 21.1 Diagnosis or Nature of Illness or Injury 69 Admit Dx
38 SECONDARY-DIAG 21.2 Diagnosis or Nature of Illness or Injury  
45 DX-3 21.3 Diagnosis or Nature of Illness or Injury 66 DX
46 DX-4 21.4 Diagnosis or Nature of Illness or Injury 66 DX
47 CLAIM-FROM-DOS-CCYYMMDD 24a Date(s) of Service
From
MM DD YY		 6 Statement Covers Period From Through
48 CLAIM -THRU-DOS-CCYYMMDD 24a Date(s) of Service
To
MM DD YY		 6 Statement Covers Period From Through
49 PLACE-OF-SERVICE 24b Place of Service  
50 CLAIM-EMERGENCY-INDICATOR 24c EMG  
51 CLAIM-UNIT-VISTS-DAYS 24g Days or Units 46 Serv Units
54 ADMIT-DATE-CCYYMMDD   12 Admission Date
55 ADMIT-HOUR   13 Admission Hr
84 ADMIT-TYPE   14 Admission Type
88 SOURCE-OF-ADMISSION   15 Admission Src

 

HMS gets data from the 1500 and UB-04 forms.

These tables show Patient, Provider, and Services fields.

The first column is the HMS field name. The next two columns show the names of the 1500 and UB-04 fields from which HMS gets data.