UB04 Code-Code Field/Qualifiers Code LOI: LOINC (Logical Observation Identifiers Names and Codes)

Overview

The UB-04 claim form utilizes specific code-code fields to provide granular clinical and administrative data necessary for claim adjudication. ^[1] While the UB-04 form is primarily a paper-based instrument, MassHealth transitioned to an all-electronic claims submission policy effective January 1, 2012, to improve processing efficiency. ^[1] Consequently, the use of qualifiers like LOI must adhere to electronic standards unless a provider has secured an approved electronic claim submission waiver. ^[1] These waivers are governed by specific administrative bulletins, such as All Provider Bulletin 217 and 223, which outline the state's paper claims waiver policy. ^[1] When paper forms are permitted, they are utilized by a wide array of facilities, including acute inpatient hospitals, chronic disease and rehabilitation centers, and community health centers. ^[1] The inclusion of LOINC data via the LOI qualifier ensures that specific diagnostic tests or clinical results are clearly communicated to the payer. [CODE: LOI, BG-UB-04 (02/21)]

When to Use

The LOI qualifier is used in the code-code fields of the UB-04 when it is necessary to report clinical information defined by the LOINC standard. [CODE: LOI] This is particularly relevant for outpatient and inpatient facilities that must provide supplemental data to support the medical necessity of specific revenue codes. ^[1] Providers such as acute outpatient hospitals, psychiatric outpatient hospitals, and substance use disorder treatment centers may utilize these fields to provide additional clinical context for the services rendered. ^[1] For instance, when a claim requires the reporting of a specific laboratory result to justify a high-cost treatment or a specialized diagnostic procedure, the LOI qualifier identifies the subsequent code as a LOINC identifier. [CODE: LOI, BG-UB-04 (02/21)] It is important to note that for outpatient claims, providers are instructed to bundle services to fit on a single form whenever possible. ^[1] If a claim requires more than 22 revenue lines, MassHealth mandates the submission of an electronic claim rather than multiple paper forms. ^[1] The use of LOI is restricted to instances where the provider has a valid reason to include clinical observation codes as part of the billing record. [CODE: LOI, BG-UB-04 (02/21)]

Step-by-Step Claim Example

To report information using the LOI qualifier on a UB-04 form, the provider must follow precise formatting rules. ^[1] First, the provider must determine if they are eligible to submit a paper claim based on an approved waiver or if they are submitting via Direct Data Entry on the POSC. ^[1] Following the qualifier, the specific LOINC code representing the clinical observation is entered. [CODE: LOI] All information must be typed or printed using black ink only to ensure legibility for scanning systems. ^[1] Dates associated with the clinical data must be formatted as MMDDYY or MMDDYYYY. ^[1] The provider must ensure that the clinical data reported via the LOI qualifier corresponds correctly to one of the revenue codes listed on the claim. ^[1] Up to 22 revenue codes can be entered per form; if the clinical documentation requires more space or lines, the provider should transition to an electronic submission. ^[1] Finally, any necessary supplemental reports or required forms must be attached to the claim before submission to MassHealth. ^[1]

Common Mistakes & Audit Red Flags

One of the most frequent errors is submitting paper claims without an approved electronic claim submission waiver. ^[1] MassHealth requires all claims to be electronic unless a formal waiver is in place; failure to adhere to this results in claim rejection. ^[1] Another common mistake is the use of incorrect ink or illegible entries. ^[1] Providers must use black ink only and avoid the use of ditto marks or shorthand like "same as above," as these are not recognized by automated processing systems. ^[1] Audit red flags often involve timing and documentation discrepancies. ^[1] Claims must be received within 90 days from the date of service or the date of the explanation of benefits from a primary insurer. ^[1] Submitting a claim beyond this 90-day window without a valid 90-day waiver request submitted via the POSC will trigger a denial. ^[1] Additionally, if the LOINC code provided under the LOI qualifier does not match the clinical services described by the revenue codes, the claim may be flagged for manual review. [CODE: LOI, BG-UB-04 (02/21)] Providers must also ensure that for members with other health insurance, they follow the supplemental instructions in Appendix A to avoid payment delays. ^[1]

Related Codes/Fields

Field/Code	Description	Source
81CC	Code-Code Field where qualifiers and codes are entered.	[CODE: LOI]
LOI	Qualifier for LOINC (Logical Observation Identifiers Names and Codes).	[CODE: LOI]
Revenue Codes	Up to 22 lines allowed per paper UB-04 claim form.	[1]
MMDDYYYY	Required date format for entries on the UB-04 form.	[1]
POSC	Provider Online Service Center for electronic submissions and waivers.	[1]
Appendix A	Supplemental instructions for Third Party Liability (TPL).	[1]

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References

[1] BG-UB-04 (02/21) — https://www.mass.gov/doc/ub-04-billing-guide-0/download