Claim Form Rule: Adding Value Codes

  • Updated

What claim change is needed?

Add value codes 01, 80, 81, or A3 to the UB-04.

  • 01: Most Common Semi-Private Rate or Billed Per Unit Rate - to provide for recording hospital's most common semi-private rate.
  • 80: Covered Days
  • 81: Non-Covered Days
  • A3: Estimated Responsibility Payer A

Box Number

UB-04: Box 39, 40, 41 - Value Code/Amount

CMS-1500: n/a


  1. In Management Center > Claim Rules, click Create Claim Form Rule.
  2. Select Claim Type - Institutional.
  3. Under Available Behaviors, select the value code.
  4. Set option Omit or Write to Claim.
  5. Set claim rule conditions.
  6. Click Save.


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