Claim Page 03 — Entering a Hospice Claim
Claim Page 03 (Map 1713) contains payer information, diagnosis code information, and attending and certifying physician information.
Key:
- RED = Required field
- BLUE = Optional field
- GREEN = Conditional field, depended on the type of claim
- PURPLE = System generated field
- BLACK = Not required field
Field Descriptions for Claim Page 03 – Map 1713
The MID, TOB, S/LOC and PROVIDER fields are system generated from information on Claim Page 01.
Field Name | UB-04 Form Locator (FL) | Description | ||||
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CD |
N/A |
Primary payer code. Valid values are: |
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PAYER |
FL 50 |
Payer name. FISS will automatically insert the payer name "Medicare" in this field when the payer code (CD field) for this line is a "Z". If a supplemental insurer is listed, or when billing Medicare conditionally, you must enter the name of the other insurer on the corresponding A, B or C line. |
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OSCAR |
FL 51 |
Medicare provider number. FISS will automatically insert your OSCAR number (also known as your PTAN) in this field when the payer code (CD field) for this line is a "Z". If a supplemental insurer is listed, or when billing Medicare conditionally, you must enter the name of the other insurer on the corresponding A, B or C line. |
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RI |
FL 52 |
Release of Information.
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SERV FAC NPI Conditionally Required |
N/A |
Enter the NPI of the nursing facility, hospital or hospice inpatient facility where the patient received services. Only required when reporting HCPCS Q5003, Q5004, Q5005, Q5006 (when not the same as the billing hospice), Q5007 and Q5008. |
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MEDICAL RECORD NBR |
FL 3b |
Beneficiary's medical record number. |
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DIAG CODES |
FL 67A - Q |
For claims with a "From" date prior to October 1, 2015, enter the ICD-9-CM diagnosis code(s) (25 codes maximum). For claims with a "From" date on or after October 1, 2015, enter the ICD-10-CM diagnosis code(s). (25 codes maximum.)
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ATT PHYS NPI |
FL 76 |
Enter the national provider identifier (NPI) of the patient's attending physician. The attending physician is identified by the patient at the time they elect the hospice benefit. If the patient does not have an attending physician, enter the NPI of the certifying physician. |
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L |
FL 76 |
Enter the last name of the attending physician. If the patient does not have an attending physician, enter the last name of the certifying physician. |
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F |
FL 76 |
Enter the first name of the attending physician. If the patient does not have an attending physician, enter the first name of the certifying physician. |
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M |
N/A |
Enter the middle initial of the attending physician. |
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REF PHYS NPI |
FL 78 and 79 |
Enter the NPI of the physician responsible for certifying the patient as terminally ill, if different than the attending physician. |
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L |
FL 78 and 79 |
Enter the last name of physician responsible for certifying the patient as terminally ill, if different than the attending physician. |
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F |
FL 78 and 79 |
Enter the first name of physician responsible for certifying the patient as terminally ill, if different than the attending physician. |
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M |
N/A |
Enter the middle initial of physician responsible for certifying the patient as terminally ill, if different than the attending physician. |
Additional FISS Claim Pages
- Notice of Elections (NOEs)/Transfer NOE
- Hospice Claims
- Notice of Election Termination/Revocation (NOTR) – 8XB
Updated: 04.12.21