1. (a) The accepted data record formats are the UB-04 1450 version 7 formats.

   1. (1) This format has altered slightly.
   2. (2) The definition specified for each data element is in general agreement with the definition in the UB-04 Users’ Manual.
   3. (3) Hospitals using data sources other than uniform billing should evaluate definitions for agreement with the definitions specified in this guide and UB-04 Users’ Manual.
   4. (4) Refer to 20 CAR § 54-108, exceptions to 1450 format, to identify possible changes to your current format.
   5. (5) Each record must be followed by a carriage-return/line-feed sequence.

2. (b) UB-04 1450 record specification.

   1. (1) The UB-04 1450 claim record is made up of a series of 321-character physical records and the 1450 Y2K claim record is made up of a series of 341-character physical records.
   2. (2) Not all of the physical claim records are used in the HDDS, such as the Claim Request Data.
   3. (3) Records not specified in the HDDS will be ignored if included in the submittal.

   4. (4)

      1. (A) Fields not referenced in the record formats may contain information but will not be processed by computer programs.
      2. (B) This also includes fields reserved for national use.
   5. (5) The exact record sequence and format of the 1450 is used for the HDDS, when possible.
   6. (6) A complete copy of the patient’s 1450 records would satisfy the requirements, with exceptions noted in 20 CAR § 54-108, exceptions to 1450 format.
   7. (7) The physical records for each claim are divided into logical subsets as follows:

      Subset 1	Patient Data - Record Codes 20-29
      Subset 2	Third Party Data - Record Codes 30-39
      Subset 3	Claim Request Data - Record Codes 40-49
      Subset 4	Inpatient Accommodations Data - Record Codes 50-59
      Subset 5	Ancillary Services Data - Record Codes 60-69
      Subset 6	Medical Data - Record Codes 70-79
      Subset 7	Physician Data - Record Codes 80-89

   8. (8) The record layouts that follow will provide the following information:

      1. (A) Record Name — The name of the data record;
      2. (B) Record Type — Code indicating the type of record;
      3. (C) Record Size — Physical length of record;
      4. (D) Required Field Annotation — An asterisk, *, denotes the field is required and must contain data if applicable;
      5. (E)

3. (i) Field Number — Field number as specified on the UB-04 1450 version 7 file layout.

   1. (ii) This number is not the Form Locator number found on the UB-04 1450 form;

      1. (F) Field Name — Name generally used with the UB-04 1450 form;

      2. (G)

         1. (i) Picture — This is the COBOL picture.
         2. (ii) Pic X is initialized to blanks and Pic 9 is initialized to zeroes.
         3. (iii) All money and date fields are Pic 9;

      3. (H)

         1. (i) Field Specification — Indicates how the data field is justified.
         2. (ii) L = Left justification and R = Right justification;

      4. (I)

         1. (i) Position.
         2. (ii) From = Leftmost position in the record (high order).
         3. (iii) Thru = Rightmost position in the record (low order); and

      5. (J) Form Locator — Number found on the UB-04 form and associated with the field in that location.

         1. (c) 1450 and 1450Y2K — Record type 10 — Provider data.
   2. (1) Only one (1) type 10 record is required per hospital per submittal.
   3. (2) Only the first type 10 record and will be processed.
   4. (3) This record type will be processed as a header record and a record type 95 will be processed as a trailer record.
   5. (4) The records encapsulated between the first type 10 and 95 will be processed using the hospital specified on the type 10 record.

   6. (5) If the Federal Tax Number is not unique to a facility or cost center, the Federal Tax Sub ID must be included.

      FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
      *	1	Record Type ‘10’	XX	L	1	2
      *	2	Federal Tax Number or EIN	9(10)	R	8	17	FL05
      *	3	Federal Tax Sub ID	X(4)	L	18	21	FL05
      *	4	National Provider Identifier (Billing Provider)	X(13)	L	22	34	FL56
      *	5	Medicaid Provider Number	X(13)	L	35	47
      *	6	Provider Telephone Number	9(10)	R	87	96	FL01
      *	7	Provider Name	X(25)	L	97	121	FL01
      *	8	Provider (Hospital) Data ID	X(4)	L	122	125
      PROVIDER ADDRESS (FIELDS 9 – 132)	126	175	FL01
      *	9	Address	X(25)	L	126	150
      *	10	City	X(25)	L	151	164
      *	11	State	XX	L	165	166
      *	12	ZIPCode	X(9)	L	167	175

      1. (d) 1450 — Record Type 20 — Patient data.

         FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
         *	1	Record Type ‘20’	XX	L	1	2
         *	2	Patient Control Number	X(20)	L	5	24	FL3A
         PATIENT NAME (FIELDS 3 – 5)			FL08
         *	3	Last Name	X(25)	L	25	49
         *	4	First Name	X(25)	L	50	74
         	5	Middle Initial	X		75	75
         OTHER PATIENT INFORMATION (FIELDS 6 – 10)
         *	6	Patient Sex	X		76	76	FL11
         *	7	Patient Birthdate (mmddccyy)	9(8)	R	77	84	FL10
         	8	Patient Marital Status	X		85	85
         *	9	Priority Of Admission	X		86	86	FL14
         *	10	Point of Origin for Admission or Visit	X		87	87	FL15
         PATIENT ADDRESS (FIELDS 11 – 15)			FL09
         *	11	Address Line 1	X(30)	L	88	117
         	12	Address Line 2	X(20)	L	118	137
         *	13	City	X(25)	L	138	162
         *	14	State	XX	L	163	164
         *	15	ZIPCode	X(9)	L	165	173
         PATIENT ADMISSION INFORMATION (FIELDS 16 – 17)
         *	16	Admission Date	9(6)	R	174	179	FL12
         *	17	Admission Hour	XX	R	180	181	FL13
         STATEMENT COVERS PERIOD (FIELDS 18 – 19)			FL06
         *	18	From (mmddyy)	9(6)	R	182	187
         *	19	Thru (mmddyy)	9(6)	R	188	193
         OTHER PATIENT HOSPITAL INFORMATION (FIELDS 2O -22)
         *	20	Patient Discharge Status	99	R	194	195	FL17
         *	21	Discharge Hour	XX	R	196	197	FL16
         *	22	Medical Record Number	X(17)	L	198	214	FL3B

4. (e) 1450Y2K — Record Type 20 — Patient data.

   FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
   *	1	Record Type ‘20’	XX	L	1	2
   *	2	Patient Control Number	X(20)	L	5	24	FL3A
   PATIENT NAME (FIELDS 3 – 5)			FL08
   *	3	Last Name	X(25)	L	25	49
   *	4	First Name	X(25)	L	50	74
   	5	Middle Initial	X		75	75
   *	6	Patient Sex	X		76	76	FL11
   *	7	Patient Birth Date (ccyymmdd)	9(8)	R	77	84	FL10
   	8	Patient Marital Status	X		85	85
   *	9	Priority Of Admission	X		86	86	FL14
   *	10	Point of Origin for Admission or Visit	X		87	87	FL15
   PATIENT ADDRESS (FIELDS 11 – 15)			FL09
   *	11	Address Line 1	X(30)	L	88	117
   	12	Address Line 2	X(20)	L	118	137
   *	13	City	X(25)	L	138	162
   *	14	State	XX	L	163	164
   *	15	ZIPCode	X(9)	L	165	173
   PATIENT ADMISSION INFORMATION (FIELDS 16 – 17)
   *	16	Admission Date (ccyymmdd)	9(8)	R	174	181	FL12
   *	17	Admission Hour	XX	R	182	183	FL13
   STATEMENT COVERS PERIOD (FIELDS 18 – 19)			FL06
   *	18	From (ccyymmdd)	9(8)	R	184	191
   *	19	Thru (ccyymmdd)	9(8)	R	192	199
   OTHER PATIENT HOSPITAL INFORMATION (FIELDS 2O -22)
   *	20	Patient Status	99	R	200	201	FL17
   *	21	Discharge Hour	XX	R	202	203	FL16
   *	22	Medical Record Number	X(17)	L	204	220	FL3B

5. (f) 1450 and 1450Y2K — Record Type 27 — Department of Health specific data.

   FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
   *	1	Record Type ‘27’	XX	L	1	2
   *	2	Sequence ‘01’	99		3	4
   *	3	Patient Control Number	X(20)	L	5	24	FL03
   *	4	Type of Bill	X(3)	L	25	27	FL04
   *	5	Patient Social Security Number	9(10)	R	28	37
   *	6	Patient Race	X		38	38
   *	7	Patient Ethnicity	X	.	39	39
   *	8	Birth Weight	9999	R	40	43
   *	9	Total Charges	9(8)V99S	R	44	53
   	10	Filler (empty fields)			54	59
   *	11	APGAR Score	9999	R	60	63
   	12	Diagnosis-Related Group (DRG)	9999	R	64	67
   	13	Major Diagnostic Categories (MDC)	99	R	68	69
   	14	Public Health Condition Code 1	X(2)	R	70	71
   	15	Public Health Condition Code 2	X(2)	R	72	73
   	16	Public Health Condition Code 3	X(2)	R	74	75
   	17	Public Health Condition Code 4	X(2)	R	76	77

6. (g) 1450 and 1450Y2K — Record Types 30-31 — Third-party payer data.

   1. (1)

      1. (A) The use of these record types for the HDDS is the same as the UB-04 claim.
      2. (B) When reporting for HDDS, records may need to be consolidated and amounts accumulated by payer.
      3. (C) Below are specifications and an example as taken from UB-04.

   2. (2)

      1. (A) One (1) third-party payer record packet (record type 30) must appear in the bill record for each payer involved in the bill.
      2. (B) Each third-party payer packet must contain a record type 30.
      3. (C) However, each record type 30 may or may not have an associated record type 31, depending on the specific third-party payer data required by the particular payer. Example: Medicare is primary, and the secondary payer requires the insured’s address.

         	Record Type Code	Seq.No.
         Medicare	30	01
         Secondary Payer	30	02
         Secondary Payer	31	02

   3. (3) Because the sequence number of the type 31 record for the secondary payer matches the sequence number of the secondary payer’s type 30 record, it serves as a matching criterion for the specific third-party payer record packet.
   4. (4) Sequence 01 represents the primary payer, sequence 02 represents the secondary payer, and sequence 03 represents the tertiary payer.
   5. (5) 1450 and 1450Y2K — Record Type 30 — Third-party payer.

      FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
      *	1	Record Type ‘30’	XX	L	1	2
      *	2	Sequence Number	99	R	3	4
      *	3	Patient Control Number	X(20)	L	5	24	FL03
      *	4	Source of Payment Code	X	L	25	25	FL50
      	5	Filler (empty fields)			26	29
      *	6	Health Plan ID	9(10)	L	30	39	FL51
      *	7	Insured’s Unique ID	X(19)	L	40	58	FL60
      	8	Filler (empty fields)			59	79
      	9	Insurance Group Number	X(17)	L	80	96	FL62
      	10	Filler (empty fields)			97	110
      INSURED’S NAME & INFORMATION (FIELDS 8-12)			FL58
      	11	Last Name	X(20)	L	111	130
      	12	First Name	X(9)	L	131	139
      	13	Middle Initial	X		140	140
      	14	Filler (empty field)			141	143
      	15	Patient Relationship to Insured	99	R	144	145	FL59
      	16	Employment Status Code	9		146	146

   6. (6) 1450 and 1450Y2K — Record Type 31 — Third-party payer.

      FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
      *	1	Record Type ‘31’	XX	L	1	2
      *	2	Sequence Number	99	R	3	4
      *	3	Patient Control Number	X(20)	L	5	24	FL03
      INSURED’S ADDRESS (FIELDS 4-8)
      	4	Address Line 1	X(18)	L	25	42
      	5	Address Line 2	X(18)	L	43	60
      	6	City	X(15)	L	61	75
      	7	State	XX	L	76	77
      	8	ZIPCode	X(9)	L	78	86
      	9	Employer Name	X(24)	L	87	110	FL65
      EMPLOYER LOCATION (FIELDS 10-13)
      	10	Employer Address	X(18)	L	111	128
      	11	Employer City	X(15)	L	129	143
      	12	Employer State	XX	L	144	145
      	13	Employer ZIPCode	X(9)	R	146	154

7. (h) 1450 and 1450Y2K — Record Type 50 — Inpatient accommodations data.

   1. (1) The sequence number for record type 50 can go from 01 to 99, each such physical record containing four (4) accommodations, thus making provision for reporting up to three hundred ninety-six (396) accommodations on a single claim.

   2. (2) Accommodation revenue codes: 100 through 21X.

      FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
      *	1	Record Type ‘50’	XX	L	1	2
      *	2	Sequence Number	99	R	3	4
      *	3	Patient Control Number	X(20)	L	5	24	FL03
      ACCOMMODATIONS (OCCURS 4 TIMES)
      ACCOMMODATIONS 1	X(42)	25	66
      *	4	Revenue Code	9(4)	R	25	28	FL42
      *	5	Accommodations Rate	9(7)V99	R	29	37	FL44
      *	6	Service Units (Accommodations Days)	9(4)	R	38	41	FL46
      *	7	Total Charges by Revenue Code	9(8)V99S	R	42	51	FL47
      	8	FILLER (empty fields)			52	66
      ACCOMMODATIONS 2	X(42)	67	108
      *	9	Revenue Code	9(4)	R	67	70	FL42
      *	10	Accommodations Rate	9(7)V99	R	71	79	FL44
      *	11	Service Units (Accommodations Days)	9(4)	R	80	83	FL46
      *	12	Total Charges by Revenue Code	9(8)V99S	R	84	93	FL47
      	13	FILLER (empty fields)			94	108
      ACCOMMODATIONS 3	X(42)	109	150
      *	14	Revenue Code	9(4)	R	109	112	FL42
      *	15	Accommodations Rate	9(7)V99	R	113	121	FL44
      *	16	Service Units (Accommodations Days)	9(4)	R	122	125	FL46
      *	17	Total Charges by Revenue Code	9(8)V99S	R	126	135	FL47
      	18	FILLER (empty fields)		R	136	150
      ACCOMMODATIONS 4	X(42)	151	192
      *	19	Revenue Code	9(4)	R	151	154	FL42
      *	20	Accommodations Rate	9(7)V99	R	155	163	FL44
      *	21	Service Units (Accommodations Days)	9(4)	R	164	167	FL46
      *	22	Total Charges by Revenue Code	9(8)V99S	R	168	177	FL47

      1. (i) 1450 and 1450Y2K — Record Type 60 — Inpatient ancillary services data.

   3. (1)

      1. (A)

         1. (i) The sequence number for record type 60 can go from 01 to 99.
         2. (ii) Each such physical record contains up to three (3) inpatient ancillary service codes, thus making provision for reporting up to two hundred ninety-seven (297) inpatient ancillary services on a single claim.
      2. (B) Payer and related information revenue codes — Codes 001 – 099.
      3. (C) Inpatient ancillary services revenue codes — Codes 220 – 99x.

         FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
         *	1	Record Type ‘60’	XX	L	1	2
         *	2	Sequence Number	99	R	3	4
         *	3	Patient Control Number	X(20)	L	5	24	FL03
         INPATIENT ANCILLARY SERVICES DATA (OCCURS 3 TIMES)
         INPATIENT ANCILLARIES 1	X(56)	25	80
         *	4	Revenue Code	9(4)	R	25	28	FL42
         	5	HCPCS / Procedure Code	X(5)	L	29	33
         	6	Modifier 1 (HCPCS & CPT 4)	X(2)	L	34	35
         	7	Modifier 2 (HCPCS & CPT 4)	X(2)	L	36	37
         *	8	Units of Service	9(7)	R	38	44	FL46
         *	9	Total charges by Revenue Code	9(8)V99S	R	45	54	FL47
         	10	FILLER (empty fields)			55	80
         INPATIENT ANCILLARIES 2	X(56)	81	136
         *	11	Revenue Code	9(4)	R	81	84	FL42
         	12	HCPCS / Procedure Code	X(5)	L	85	89
         	13	Modifier 1 (HCPCS & CPT 4)	X(2)	L	90	91
         	14	Modifier 2 (HCPCS & CPT 4)	X(2)	L	92	93
         *	15	Units of Service	9(7)	R	94	100	FL46
         *	16	Total Charges by Revenue Code	9(8)V99S	R	101	110	FL47
         	17	FILLER (empty fields)			111	136
         INPATIENT ANCILLARIES 3	X(56)	137	166
         *	18	Revenue Code	9(4)	R	137	140	FL42
         	19	HCPCS / Procedure Code	X(5)	L	141	145
         	20	Modifier 1 (HCPCS & CPT 4)	X(2)	L	146	147
         	21	Modifier 2 (HCPCS & CPT 4)	X(2)	L	148	149
         *	22	Units of Service	9(7)	R	150	156	FL46
         *	23	Total Charges by Revenue Code	9(8)V99S	R	157	166	FL47

   4. (2) Identical revenue codes should be combined and their charges added together for reporting purposes.

8. (j) Record Type 70 sequences 1, 2, and 3.

   1. (1) Sequence 1 — 1450 and 1450Y2K — Medical data (Diagnosis and Present on Admission codes).

      FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
      *	1	Record Type ‘70’	XX	L	1	2
      *	2	Sequence ‘01’	XX	R	3	4
      *	3	Patient Control Number	X(20)	L	5	24	FL03
      *	4	Principal Diagnosis Code	X(7)	L	25	31	FL67
      *	5	Other Diagnosis Code 1	X(7)	L	32	38	FL67A
      *	6	Other Diagnosis Code 2	X(7)	L	39	45	FL67B
      *	7	Other Diagnosis Code 3	X(7)	L	46	52	FL67C
      *	8	Other Diagnosis Code 4	X(7)	L	53	59	FL67D
      *	9	Other Diagnosis Code 5	X(7)	L	60	66	FL67E
      *	10	Other Diagnosis Code 6	X(7)	L	67	73	FL67F
      *	11	Other Diagnosis Code 7	X(7)	L	74	80	FL67G
      *	12	Other Diagnosis Code 8	X(7)	L	81	87	FL67H
      *	13	Other Diagnosis Code 9	X(7)	L	88	94	FL67I
      *	14	Other Diagnosis Code 10	X(7)	L	95	101	FL67J
      *	15	Other Diagnosis Code 11	X(7)	L	102	108	FL67K
      *	16	Other Diagnosis Code 12	X(7)	L	109	115	FL67L
      *	17	Other Diagnosis Code 13	X(7)	L	116	122	FL67M
      *	18	Other Diagnosis Code 14	X(7)	L	123	129	FL67N
      *	19	Other Diagnosis Code 15	X(7)	L	130	136	FL67O
      *	20	Other Diagnosis Code 16	X(7)	L	137	143	FL67P
      *	21	Other Diagnosis Code 17	X(7)	L	144	150	FL67Q
      *	22	Other Diagnosis Code 18	X(7)	L	151	157
      *	23	Other Diagnosis Code 19	X(7)	L	158	164
      *	24	Other Diagnosis Code 20	X(7)	L	165	171
      *	25	Other Diagnosis Code 21	X(7)	L	172	178
      *	26	Other Diagnosis Code 22	X(7)	L	179	185
      *	27	Other Diagnosis Code 23	X(7)	L	186	192
      *	28	Other Diagnosis Code 24	X(7)	L	193	199
      *	29	Other Diagnosis Code 25	X(7)	L	200	206
      *	30	Other Diagnosis Code 26	X(7)	L	207	213
      *	31	Other Diagnosis Code 27	X(7)	L	214	220
      *	32	Other Diagnosis Code 28	X(7)	L	221	227
      *	33	Other Diagnosis Code 29	X(7)	L	228	234
      *	34	POA – Present on Admission	X(1)	L	235	235	FL67
      *	35	POA 1 – Present on Admission	X(1)		236	236	FL67A
      *	36	POA 2 – Present on Admission	X(1)		237	237	FL67B
      *	37	POA 3 – Present on Admission	X(1)		238	238	FL67C
      *	38	POA 4 – Present on Admission	X(1)		239	239	FL67D
      *	39	POA 5 – Present on Admission	X(1)		240	240	FL67E
      *	40	POA 6 – Present on Admission	X(1)		241	241	FL67F
      *	41	POA 7 – Present on Admission	X(1)		242	242	FL67G
      *	42	POA 8 – Present on Admission	X(1)		243	243	FL67H
      *	43	POA 9 – Present on Admission	X(1)		244	244	FL67I
      *	44	POA 10 – Present on Admission	X(1)		245	245	FL67J
      *	45	POA 11 – Present on Admission	X(1)		246	246	FL67K
      *	46	POA 12 – Present on Admission	X(1)		247	247	FL67L
      *	47	POA 13 – Present on Admission	X(1)		248	248	FL67M
      *	48	POA 14 - Present on Admission	X(1)		249	249	FL67N
      *	49	POA 15 – Present on Admission	X(1)		250	250	FL67O
      *	50	POA 16 – Present on Admission	X(1)		251	251	FL67P
      *	51	POA 17 – Present on Admission	X(1)		252	252	FL67Q
      *	52	POA 18 – Present on Admission	X(1)		253	253
      *	53	POA 19 – Present on Admission	X(1)		254	254
      *	54	POA 20 – Present on Admission	X(1)		255	255
      *	55	POA 21 – Present on Admission	X(1)		256	256
      *	56	POA 22 – Present on Admission	X(1)		257	257
      *	57	POA 23 – Present on Admission	X(1)		258	258
      *	58	POA 24 – Present on Admission	X(1)		259	259
      *	59	POA 25 – Present on Admission	X(1)		260	260
      *	60	POA 26 – Present on Admission	X(1)		261	261
      *	61	POA 27 – Present on Admission	X(1)		262	262
      *	62	POA 28 – Present on Admission	X(1)		263	263
      *	63	POA 29 – Present on Admission	X(1)		264	264

   2. (2) Sequence 2 — 1450 and 1450Y2K — Medical data (Admitting Diagnosis and External Cause of Injury).

      FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
      *	1	Record Type ‘70’	XX	L	1	2
      *	2	Sequence ‘02’	XX	R	3	4
      *	3	Patient Control Number	X(20)	L	5	24	FL3A
      *	4	Admitting Diagnosis Code	X(8)	L	25	32	FL69
      *	5	External Cause of Injury Code 1	X(8)	L	33	40	FL72
      *	6	External Cause of Injury Code 2	X(8)	L	41	48	FL72
      *	7	External Cause of Injury Code 3	X(8)	L	49	56	FL72
      *	8	External Cause of Injury Code 4	X(8)	L	57	64
      *	9	External Cause of Injury Code 5	X(8)	L	65	72
      *	10	External Cause of Injury Code 6	X(8)	L	73	80
      *	11	External Cause of Injury Code 7	X(8)	L	81	88
      *	12	External Cause of Injury Code 8	X(8)	L	89	96
      *	13	External Cause of Injury Code 9	X(8)	L	97	104
      *	14	External Cause of Injury Code 10	X(8)	L	105	112

   3. (3) Sequence 3 — 1450 — Medical data (Procedures).

      FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
      *	1	Record Type ’70’	XX	L	1	2
      *	2	Sequence ’’03’	XX	R	3	4
      *	3	Patient Control Number	X(20)	L	5	24	FL3A
      *	4	Principal Procedure Code	X(8)	L	25	32	FL74
      *	5	Principal Procedure Code Date (mmddyy)	X(6)	L	33	38	FL74
      *	6	Other Procedure Code 1	X(8)	L	39	46	FL74A
      *	7	OPC 1 – Date (mmddyy)	X(6)	R	47	52	FL74A
      *	8	Other Procedure Code 2	X(8)	L	53	60	FL74B
      *	9	OPC 2 – Date (mmddyy)	X(6)	R	61	66	FL74B
      *	10	Other Procedure Code 3	X(8)	L	67	74	FL74C
      *	11	OPC 3 – Date (mmddyy)	X(6)	R	75	80	FL74C
      *	12	Other Procedure Code 4	X(8)	L	81	88	FL74D
      *	13	OPC 4 – Date (mmddyy)	X(6)	R	89	94	FL74D
      *	14	Other Procedure Code 5	X(8)	L	95	102	FL74E
      *	15	OPC 5 – Date (mmddyy)	X(6)	R	103	108	FL74E
      *	16	Other Procedure Code 6	X(8)	L	109	116
      *	17	OPC 6 – Date (mmddyy)	X(6)	R	117	122
      *	18	Other Procedure Code 7	X(8)	L	123	130
      *	19	OPC 7 – Date (mmddyy)	X(6)	R	131	136
      *	20	Other Procedure Code 8	X(8)	L	137	144
      *	21	OPC 8 – Date (mmddyy)	X(6)	R	145	150
      *	22	Other Procedure Code 9	X(8)	L	151	158
      *	23	OPC 9 – Date (mmddyy)	X(6)	R	159	164
      *	24	Other Procedure Code 10	X(8)	L	165	172
      *	25	OPC 10 – Date (mmddyy)	X(6)	R	173	180
      *	26	Other Procedure Code 11	X(8)	L	181	188
      *	27	OPC 11 – Date (mmddyy)	X(6)	R	189	194
      *	28	Other Procedure Code 12	X(8)	L	195	202
      *	29	OPC 12 – Date (mmddyy)	X(6)	R	203	208
      *	30	Other Procedure Code 13	X(8)	L	209	216
      *	31	OPC 13 – Date (mmddyy)	X(6)	R	217	222
      *	32	Other Procedure Code 14	X(8)	L	223	230
      *	33	OPC 14 – Date (mmddyy)	X(6)	R	231	236
      *	34	Other Procedure Code 15	X(8)	L	237	244
      *	35	OPC 15 – Date (mmddyy)	X(6)	R	245	250
      *	36	Other Procedure Code 16	X(8)	L	251	258
      *	37	OPC 16 – Date (mmddyy)	X(6)	R	259	264
      *	38	Other Procedure Code 17	X(8)	L	265	272
      *	39	OPC 17 – Date (mmddyy)	X(6)	R	273	278
      *	40	Other Procedure Code 18	X(8)	L	279	286
      *	41	OPC 18 – Date (mmddyy)	X(6)	R	287	292
      *	42	Other Procedure Code 19	X(8)	L	293	300
      *	43	OPC 19 – Date (mmddyy)	X(6)	R	301	306
      *	44	Other Procedure Code 20	X(8)	L	307	314
      *	45	OPC 20 – Date (mmddyy)	X(6)	R	315	320
      *	46	Procedure Coding Method Used	9(1)		321	321

   4. (4) Sequence 3 — 1450Y2K — Medical data (Procedures).

      FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
      *	1	Record Type ‘70’	XX	L	1	2
      *	2	Sequence ’03’	XX	R	3	4
      *	3	Patient Control Number	X(20)	L	5	24	FL3A
      *	4	Principal Procedure Code	X(8)	L	25	32	FL74
      *	5	Principal Procedure Code Date (ccyymmdd)	X(8)	L	33	40
      *	6	Other Procedure Code 1	X(8)	L	41	48	FL74A
      *	7	OPC 1 – Date (ccyymmdd)	X(8)	R	49	56
      *	8	Other Procedure Code 2	X(8)	L	57	64	FL74B
      *	9	OPC 2 – Date (ccyymmdd)	X(8)	R	65	72
      *	10	Other Procedure Code 3	X(8)	L	73	80	FL74C
      *	11	OPC 3 – Date (ccyymmdd)	X(8)	R	81	88
      *	12	Other Procedure Code 4	X(8)	L	89	96	FL74D
      *	13	OPC 4 – Date (ccyymmdd)	X(8)	R	97	104
      *	14	Other Procedure Code 5	X(8)	L	105	112	FL74E
      *	15	OPC 5 – Date (ccyymmdd)	X(8)	R	113	120
      *	16	Other Procedure Code 6	X(8)	L	121	128
      *	17	OPC 6 – Date (ccyymmdd)	X(8)	R	129	136
      *	18	Other Procedure Code 7	X(8)	L	137	144
      *	19	OPC 7 – Date (ccyymmdd)	X(8)	R	145	152
      *	20	Other Procedure Code 8	X(8)	L	153	160
      *	21	OPC 8 – Date (ccyymmdd)	X(8)	R	161	168
      *	22	Other Procedure Code 9	X(8)	L	169	176
      *	23	OPC 9 – Date (ccyymmdd)	X(8)	R	177	184
      *	24	Other Procedure Code 10	X(8)	L	185	192
      *	25	OPC 10 – Date (ccyymmdd)	X(8)	R	193	200
      *	26	Other Procedure Code 11	X(8)	L	201	208
      *	27	OPC 11 – Date (ccyymmdd)	X(8)	R	209	216
      *	28	Other Procedure Code 12	X(8)	L	217	224
      *	29	OPC 12 – Date (ccyymmdd)	X(8)	R	225	232
      *	30	Other Procedure Code 13	X(8)	L	233	240
      *	31	OPC 13 – Date (ccyymmdd)	X(8)	R	241	248
      *	32	Other Procedure Code 14	X(8)	L	249	256
      *	33	OPC 14 – Date (ccyymmdd)	X(8)	R	257	264
      *	34	Other Procedure Code 15	X(8)	L	265	272
      *	35	OPC 15 – Date (ccyymmdd)	X(8)	R	273	280
      *	36	Other Procedure Code 16	X(8)	L	281	288
      *	37	OPC 16 – Date (ccyymmdd)	X(8)	R	289	296
      *	38	Other Procedure Code 17	X(8)	L	297	304
      *	39	OPC 17 – Date (ccyymmdd)	X(8)	R	305	312
      *	40	Other Procedure Code 18	X(8)	L	313	320
      *	41	OPC 18 – Date (ccyymmdd)	X(8)	R	321	328
      *	42	Other Procedure Code 19	X(8)	L	329	336
      *	43	OPC 19 – Date (ccyymmdd)	X(8)	R	337	344
      *	44	Other Procedure Code 20	X(8)	L	345	352
      *	45	OPC 20 – Date (ccyymmdd)	X(8)	R	353	360
      *	46	Procedure Coding Method Used	9(1)		361	361

      1. (A) ICD coding is required for diagnosis.
      2. (B) Do not report the decimal in the code.
      3. (C) The ICD diagnosis codes are assigned a COBOL picture of X.

9. (k) 1450 and 1450Y2K — Record Type 80 – 8N — Physician data.

   FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
   *	1	Record Type ‘80’	XX	L	1	2
   *	2	Sequence	99	R	3	4
   *	3	Patient Control Number	X(20)	L	5	24	FL03
   	4	Filler (empty fields)			25	26
   *	5	Attending Provider Identifier	9(10)	L	27	36	FL76
   	6	Filler (empty fields)			37	42
   *	7	Operating Physician Identifier	9(10)	L	43	52	FL77
   	8	Filler (empty fields)			53	58
   *	9	Other Physician Identifier	9(10)	L	59	68	FL78
   	10	Filler (empty fields)			69	74
   *	11	Other Physician Identifier	9(10)	L	75	84	FL79
   	12	Filler (empty fields)			84	90
   *	13	Attending Provider Name	X(25)	L	91	115
   		Last Name	X(16)	L	91	106
   		First Name	X(8)	L	107	114
   		Middle Initial	X		115	115
   FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
   	11	Operating Physician Name	X(25)	L	116	140
   	12	Other Physician Name	X(25)	L	141	165
   	13	Other Physician Name	X(25)	L	166	190

   1. (l) 1450 and 1450Y2K — Record Type 95 — Provider Batch Control.
   2. (1) Only one (1) type 10 and type 95 record is required per hospital per submittal.
   3. (2) Record type 95 will be processed as a trailer record.
   4. (3) The Federal Tax Number must match the type 10 record.
   5. (4) The record type 10 will be processed as a header record.
   6. (5) Federal Tax Sub ID must be the same as specified on the type 10 record.
   7. (6) Number of Claims should be the number of discharges in the batch (number of type 20 records).

      FIELD NO.	NAME	PICTURE	SPEC	POSITIONFROM THRU	FORM LOCATOR
      *	1	Record Type ‘95’	XX	L	1	2
      *	2	Federal Tax Number (EIN)	9(10)	R	3	12	FL05
      *	3	Federal Tax Sub ID	X(4)	L	13	16	FL05
      *	4	Number of Claims	9(6)	R	25	30

Codification Notes: "CBOL" means common business oriented language. "ICD" means International Classification of Diseases.