FCEP-F Sample
Full claims package - UBR-F, UBD-F, CS-F and MRRP-F 

UBR-F



UBD-F Sample of other form locator data elements TOB	
facility type	Bill Classification	Bill frequency 
110	Hospital Inpatient Nonpayment/Zero Claim 
111	Hospital Inpatient	Admit-Through-Discharge Claim 
112	Hospital Inpatient	Interim--First Claim 
113	Hospital Inpatient	Interim--Continuing Claim 
114	Hospital Inpatient	Interim--Last Claim 
116	Hospital Inpatient Adjustment Of Prior Claim 
117	Hospital Inpatient	Replacement Of Prior Claim 
118	Hospital Inpatient	Void/Cancel Of A Prior Claim 
120	Hospital Inpatient Medicare Part B Only	Nonpayment/Zero Claim 
121	Hospital Inpatient Medicare Part B Only	Admit-Through-Discharge Claim 
122	Hospital Inpatient Medicare Part B Only	Interim--First Claim 
123	Hospital Inpatient Medicare Part B Only	Interim--Continuing Claim 
124	Hospital Inpatient Medicare Part B Only	Interim--Last Claim 
126	Hospital Inpatient Medicare Part B Only	Adjustment Of Prior Claim 
127	Hospital Inpatient Medicare Part B Only	Replacement Of Prior Claim 
128	Hospital Inpatient Medicare Part B Only	Void/Cancel Of A Prior Claim


CS-F Sample Claims Status File (3 data sets)
CSS-F. -- claims status code file
Code	Description	Note
0	Cannot provide further status electronically.
1	For more detailed information, see remittance advice.
2	More detailed information in letter.
3	Claim has been adjudicated and is awaiting payment cycle.
4	This is a subsequent request for information from the original request.
5	This is a final request for information.
6	Balance due from the subscriber.
7	Claim may be reconsidered at a future date.
8	No payment due to contract/plan provisions.	Note: Inactive as of ASC X12 Version 4020. Refer to 107 for new verbiage.
CSA-F. -- claims adjustment reason codes file
Code	Description	Note
1	Deductible Amount
2	Coinsurance Amount
3	Co-payment Amount
4	The procedure code is inconsistent with the modifier used or a required modifier is missing.
CSC-F. -- claims status category file
Code	Description	Note
A0	Acknowledgement/Forwarded-The claim/encounter has been forwarded to another entity.	
A1	Acknowledgement/Receipt-The claim/encounter has been received. This does not mean that the claim has been accepted for adjudication.	
A2	Acknowledgement/Acceptance into adjudication system-The claim/encounter has been accepted into the adjudication system.	



MRRP-F