This manual is designed to assist facilities with their phc4 inpatient data submission. No other publication governmental or privatecommercial can be considered authoritative. Committees official ub04 data specifications manual. Blue cross and blue shield of oklahoma offers this guide to help you complete the ub04 form for your patients with blue cross facility coverage. Ub04 claim form instructions form locator name instructions 1. Blue cross and blue shield of texas offers this guide to help you complete the ub 04 form for your patients with blue cross facility coverage. These instructions are to be supplemented with the information and codes in the uniform billing manual for the ub04.
Ub04 billing guide for bill type 26 billing keystone first the document following provider types in successfully completing the ub04 claim form. Request for temporary total compensation c84 to document 70 on ub04. In the field column of the table below, some field numbers are preceded with an asterisk. Ub04 claim form this document explains the ub04 claim form, which is used for submitting claims for reimbursement for specially designated facilities. Admission source enter the appropriate admission or visit referral source code.
Specific codes required refer to ub04 manual ra 14 priority type of visit enter the 1digit code indicating the priority of this admissionvisit. This form, also known as the ub04, is a uniform institutional provider bill. The purpose of this document is to provide a blockbyblock reference guide to assist the following provider types in successfully completing the ub04. What are 837 i format and cms 1450 claim cms 1500 claim.
All ub04 claims submitted via paper and the provider portal should follow the instructions in this. Medica follows national and state uniform billing guidelines for the submission of ub04 claim forms, although some fields required by medicare or other payers may not be necessary for medica claims. Ub 04 requirements for hfs adjudication attachment to ub 04 billing instructions notice 1208 inpatient claims page 1 instructions for completion of this form follow in the order entries appear on the form. Chapter 25 completing and processing the form cms1450 data set. Submitting the claim form with all required fields will assist us in paying your claim in a timely manner. Dec 15, 2014 the 837i institutional is the standard format used by institutional providers to transmit health care claims electronically. Pay to address pay to address if different than field 1. Jun 1, 2014 of mailing of the final order of allowance of the claim or the condition being treated. Ub04 claim form instructions the new claim form supports the use. History and overview requirements residency, age, income, insurance services available cancer treatment.
All code values listed in the nubc ub04 reference manual for each form locator may not be. The security health plan processing system is designed to process standard health insurance claim forms ub 04 using revenue codes, health care common procedure coding system hcpcs with appropriate modifiers and icd10cm diagnosis codes. Instructions for completing the ub04 form locator no. Dollar amounts to the left of the vertical line should be right justified. Blue cross and blue shield of new mexico offers this guide for completion of the ub04 form for your patients with blue cross facility coverage. When submitting claims, complete all items required by each payer who is to receive a copy of the form. The ub 04 claim form and npi the ub 04 claim form includes several fields that accommodate the use of your npi.
Ub04 hospital instructions table of contents introduction 7 electronic verification system evs 9 sample ub04 11 ub04 form locators fl 01 billing provider name, address, and telephone number 12 fl 02 payto name and address 12 fl 03a patient control number 12 fl 03b medicalhealth record number 12 fl 04 type of bill 12. Billing committee nubc ub04 data specifications manual. Ub04 form and instructions claims for home health services must be filed by electronic claims submission 837i or on the ub 04 claim form. Claims with discharge date on or after january 1, 2014 will be reimbursed using the allpatient refined diagnosis related group aprdrg. The centers for medicare and medicaid services cms form 1450, referred to as the ub 04, is the standard claim form used to bill facility services to us and our affiliates. Description instructions alerts 1 provider name, address, telephone number required. Manual content the manual is made up of the following sections.
These values are valid for paper claim submission on the ub04 claim form only. The ub 04 claim form accommodates the national provider identifier npi and has incorporated other important changes. Health first colorado ub04 inpatientoutpatient billing. Enter the dollar amount for the associated value code. Inside is a blank ub04 claim form for reference, and information on medica s requirements for successful completion of the ub04 claim form. History and overview requirements residency, age, income, insurance. Effective january 1, 2014, aprdrg version 30 became the reimbursement methodology for all claims with dates of discharge on or after january 1, 2014. Quest integration instructions for completing the ub04 claim form. Medicare claims processing manual, chapter 25 pub 4 medicare claims processing security health plan considers a claim complete when the following data elements are submitted numbered as shown on the claim form. Ub04 requirements for hfs adjudication attachment to ub04. Refer to the following resource for guidelines on completing the ub04. Macs may include a crosswalk between the asc x12n 837i and the cms1450 on their websites. August 2020 this section describes ub04 claim fields that must be completed accurately and completely in order to avoid claim suspense or denial. Committees official ub04 data specifications manual noncovered charges enter any noncovered charges as it pertains to related revenue code.
This form, also known as the ub04, is a uniform institutional provider bill suitable for. Ub04 claim form and instructions amerihealth new jersey. Please find below both the hcfa1500 and ub04 user manuals and instructions. The ub 04 claim form is a hardcopy facility claim form recently redesigned to accommodate various changes to facility claims filing necessitated by current and upcoming governmental initiatives. Admission source r enter the appropriate admission or visit referral source code. If the patient is treated as an outpatient in a hospital different from the one in which the patient is registered, the services must be billed by the treating hospital using the ub04. Hmsa has determined that it will use the national uniform billing committee nubc official ub04 data specifications manual as the. About this manual aim of the manual this manual is aimed to provide all the necessary information for development engineers to develop, design, and install pos system, or to develop and design printer applications. They correspond to the ub04 forms different sections through their number designation.
Although the form is similar in appearance to the older version of the facility claim form, ub 92, a number of fields have been moved or expanded and. And the claim contains programapproved cpt, icd9, revenue and place of service codes. Jan 3, 2016 identify the provider manual sections regarding ub04 claim form completion ub04 special billing instructions for inpatient services ub spec ip. For a current list of patient status codes, please refer to the nubc ub04 manual. The national uniform billing committee nubc makes their ub04 manual available through their website. Paper ub04 forms should have all relevant information completed prior to sending the claims to eastpointe. The following instructions explain how to complete the ub04 claim form and whether a field is required, required if applicable, or not required. Description instructions alerts 1828 condition codes leave blank.
A primary payer b secondary payer c tertiary payer all information in field 50, 54, 60, and 63 should follow the instructions listed below. Detail record quick reference includes ub04 form locator. In these fields, use hipaacompliant codes that are current for the dates of service on the claim. Completing the ub04 claim form guidelines for facility. The 5010 file format also accommodates icd10cm and icd10pcs codes effective for all discharges on or after october 1, 2015. Discharge hour s enter the appropriate twodigit discharge code referring to the hour during.
This manual contains the updated specifications for the data elements and codes included on the cms1450 and used in the 837i transaction standard. Instructions for completing the ub 04 claim form the ub04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities for example, outpatient departments, rural health clinics, chronic dialysis and adult day health care. Attachment to ub04 billing instructions notice 1208 inpatient claims inpatient claims page 7 required 81. Sample ub 04 forms for inpatient and outpatient claims can be found on pages 3 and 4. Because it serves many payers, a particular payer may not need some data elements. Tips below are designed to supplement instructions in the ub04 completion. Ub04 form the uniform bill ub04 is the standardized billing form for institutional services. It is to be used as a companion to, and not a replacement. Electronic data interchange edi for medical and hospital claims. Ub 04 form the uniform bill ub 04 is the standardized billing form for institutional services. The ub04 claim form and npi the ub04 claim form includes several fields that accommodate the use of your npi. Discharge hour enter the appropriate twodigit discharge code referring to the hour during. Ub 04 claim form instructions form locator name instructions 1. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual.
For more information on noncwered charges, refer to the national uniform billing committees official ub04data specifications manual. The instructions included in this section are excerpts from medicare instructions rev. The ub04 claim form accommodates the national provider identifier npi and has incorporated other important changes. Admission type r enter the appropriate twodigit type of visit priority code for the admissionvisit. Refer to the ub04 data specifications manual for usage requirements. For information on the ub 04 billing form, or to obtain an official ub 04 data specifications. We have great deals in ub04 form cases for pinfeed and laser printers. Chars procedure manual washington state department of health. Ub04 form and instructions pages 15 page 3 of 15 appendix e locator no. Apr 24, 2015 ub04 desk reference feb 21, 2014 837 institutionalub04 claim form. Blue cross and blue shield of texas offers this guide to help you complete the ub04 form for your patients with blue cross facility coverage.
Medicare card codes adjustment reason code on ub04. This form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. This document will give you instructions, detailing each specific form field. This manual gives detailed line by line instructions on how to complete the ub04 claim form. The multiple pages should be attached to each other. Ub04 billing guide for promise icfmr, icforcs and state mr centers purpose of the document document format. The file header rows are taken from the users excel column headings, and you must match your headings to the form, using the link to dropdown boxes.
Codecode field hfs requirement needed for adjudication qualifier b3 healthcare provider taxonomy. Medicare card codes occurrence codes 01 vs 02 ub04 cms 2014. Ub04 claim form instructions the new claim form supports the use dhs. Inpatient services in the part 2 inpatient services manual for billing instructions for services rendered to a registered hospital inpatient. Summary of inpatient hospital claims grouper versions based on discharge date. Oct 08, 2016 sep 30, 2015 special instructions and examples for cms 1500, ub04 and edi 837 claims 38. Sample ub 04 forms for inpatient and outpatient claims can be found on pages 4 and 5. Ub04 instructions the blocks divided into rows a, b, c reflect the following. Find great prices today on ub04 forms hcfa 1450, the claim forms that replaced ub92 forms. Enter the name first, middle initial, last followed by the. Transmittal 2874, dated february 6, 2014, is being rescinded and.
Patient control number enter your facilitys unique account number. Sample ub04 forms for inpatient and outpatient claims can be found on pages 3 and 4. Comprehensive hospital abstract reporting system chars companion guide for chars 837i 5010r5. This manual, ed by the american hospital association, is the only official source of ub data.
It will also explain how to process the ub04 cms 1450 medical form. Overview of the ub04 billing claim form verywell health. Excel file manual import allows the user to import from their. The ub 04 is a uniform institutional bill suitable for use in billing multiple third party liability tpl payers. Health first colorado ub04 nursing facility billing manual. Refer to the following resource for guidelines on completing the ub 04. Chars 837i 5040 companion guide washington state department. Comply with the ub04 manuals instructions on claims processing requirements.
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