Prior to these requirements, the revenue description field area of the ub 04 has been used to describe the corresponding revenue code billed to medicare. Billing providers payto name, address, city, state, zip, and id if it is different from. The ub04, also known as the form cms1450, is the uniform institutional provider hardcopy claim form suitable for use in billing multiple third party payers. Ub 04 claim form e december 2018 3 ub 04 claim form description the ub 04 claim form is used to request reimbursement for services rendered by the following institutions. 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. The ub04 claim form is a hardcopy facility claim form recently redesigned to accommodate various changes to facility claims filing necessitated by current and upcoming. The ub04 uniform billing form is the standard claim form that any institutional provider can use for the billing of medical and mental health claims. Bluecross blueshield of western new york will only. Description fl01 billing provider name fl01 billing provider street. Instructions for completing the ub04 form fields marked with an asterisk.
Type of bill 1st position 3rd postion medical billing. Please also see the attachments at the end of this guide for quick instructional tools that can also be utilized as a reference guide and tool for the ub04. Jul 17, 2016 ub 04 provider identifying field instruction, a. Ub04 form at a glance interactive macpractice helpdesk. The form details all of the reimbursable care received by patients, including the relevant revenue codes for the payer.
Rather, you should use them in conjunction with the ub04 data specifications manual and the icd9cm official guidelines for coding and reporting to facilitate the assignment of the present on admission poa indicator for each principal diagnosis and other diagnoses codes reported on claim forms ub04 and 837 institutional. Present of admission poa indicator list on ub 04 medicare. Sample ub04 forms for inpatient and outpatient claims can be found on pages 3 and 4. Each form locator contains a three digit field in which to key the. The total charge field eliminates the need for rev code 001. Note that on paper claims the poa is the eighth digit of the principal diagnosis field fl 67, and the eighth digit of each of the secondary diagnosis.
See the link below to navigate to the interactive claim form. Sample ub 04 forms for inpatient and outpatient claims can be found on pages 3 and 4. Although a majority of these claims must be filed electronically, the ub 04 is distinguished by white standard paper with red ink. Ub04 claim form and instructions amerihealth hmo, inc. Ub04 claim form instructions form locator name instructions 1. Completing the ub04 claim form guidelines for facility. Please refer to the following documentation for appropriate.
The ub04 form serves as a show of room bills and summarizes the prices of all patient health care services provided at the right time to assess their care. The ub 04 uniform billing form is the standard claim form that any institutional provider can use for the billing of medical and mental health claims. Tips for completing the ub04 cms 1450 claim form failure to provide valid information matching the insureds id card could result in a rejection of your claim. 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. Value codes 3941 value codes for hospice services, enter code 61 and the costbased statistical area cbsa code for your servicecounty as a dollar amount. Ub04 data field requirements independence blue cross. Ub 04 or ub 92 billing instruction ub form feilds and descriptions box. Cms1450 ub04 field specifications effective march 1, 2007, bluecross blueshield of tennessee began accepting the new ub04 claim form. This requirement applies to all provider types and all part b bill types. Ub 04 claim form instructions form locator name instructions 1. Instructions for completing the ub04 claim form the ub04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities for example, outpatient departments, rural. Its important that each of the ub04 fields is filled out correctly to ensure a smooth process.
Enter the recipient name exactly as it is printed on the medical care ientification. Nov 15, 2016 the cms1450 form aka ub 04 at present can be used by an institutional provider to bill a medicare administrative contractor mac when a provider qualifies for a waiver from the administrative simplification compliance act asca requirement for electronic submission of claims. Ub04 claim form instructions geisinger health plan. For information on the ub 04 billing form, or to obtain an official ub 04 data specifications. When providers are submitting claims, please note that bluecross blueshield of wny will only accept the ub 04 claim form. Use only the physical address for the service facility location field. Revenue code description, investigational device exemption ide number.
Enter the name, address, and louisiana medicaid id of the provider if. Enter 2 digit value code and dollar amount or number of days. Enter the name and address of the billing provider. The next section will provide detailed instructions and descriptions on the ub04 form. Aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare pdf. This guide is designed to highlight the fields of the ub04 claim form that are required when submitting to bluecross blueshield of western new york.
Value codes 3941 value codes for hospice services, enter code 61 and the costbased statistical area cbsa code for. On a noncolor printout, required fields will appear darkest. 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. 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.
Description fl01 billing provider name fl01 billing provider street address fl01 billing provider city, state, zip fl01 billing provider telephone, fax, country code. A ub04 with field descriptions and instructions is included in the link below. A field by field explanation of the ub04 claim form. Type of bill 1st position 3rd postion place of service crosswalk type of bill located on the national uniform billing committee nubc approved ub04 claim form, also known as cms. Blue cross and blue shield of texas offers this guide to help you complete the ub04 form for your patients with. Box 56 npi facility npi should be submitted in this field. New york state electronic medicaid system ub04 billing. This guide is designed to highlight the fields of the ub 04 claim form that are required when submitting to us. Inpatient hospital facilities, such as medicalsurgical intensive care, burn care, coronary care and ancillary charges such as labor and delivery, anesthesiology and. Tips for completing the ub04 cms 1450 claim form page 1 of 17 field field description field type instructions 1 facility name, address, telephone number, and country code. Please refer to the following documentation for appropriate formatting when submitting data in these new or updated form locator fl. The ub 04 claim form and npi the ub 04 claim form includes several fields that accommodate the use of your npi.
There are 81 entry fields or boxes on the 837i and cms1450 uniform institutional claim form. In these fields, use hipaacompliant codes that are current for the dates of service on the claim. This fourdigit alphanumeric code gives three specific pieces of information after a leading zero. Aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare pdf download. Pay to address pay to address if different than field 1. The ub04 claim form includes several fields that accommodate the use of your npi. Ub 04 or ub 92 billing instruction medical billing and. The ub 04 form is popular among all insurance carriers. Jan 22, 2019 it has developed and evolved into one of the most commonly used forms for billing medical and mental health claims. Ub 04 claim form information on form fields this information can also be located in the vshp provider manual online. Field by field explanation of the cms1500 form web based. After you click on create you will be able to create a new ub04 claim. Prior to these requirements, the revenue description field area of the ub.
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. This claim form allows you to click in a specific claim field to find where the data needs to be entered in macpractice. Form locators and field descriptions federal tax identification field locator. Instructions for completing the ub04 claim form san francisco.
Covered days is reported with value code 80, which must be entered in form locator 3941 of the ub04. Mastering the ub04 claim form a field by field explanation of the ub04 claim form. New york state electronic medicaid system ub04 billing guidelines. Ub 04 field 4 the type of bill is a fourdigit code in which the first digit, a leading zero, is dropped. Ub 04 form locators bluecross blueshield of tennessee. The ub04 claim form locator descriptions table 2 indicates in bold type if a field is required or required. Ub form billing field descriptions medical billing and coding. Although the form accommodates the npi, you may continue to report your current provider identification numbers in the appropriate areas of the form. Field by field explanation of the cms1500 form web. It has developed and evolved into one of the most commonly used forms for billing medical and mental health claims. The ub04 manual national uniform billing data element specifications as developed by the national uniform billing committee current revision should be used in conjunction with this provider billing.
The ub04 is the uniform billing form for institutional providers. Ub 04 provider type identifying field instruction, cms. Ub 04 form the uniform bill ub 04 is the standardized billing form for institutional services. The cms1450 form aka ub04 at present can be used by an institutional provider to bill a medicare administrative contractor mac when a provider qualifies for a waiver from the. In the field column of the table below, some field numbers are preceded with an asterisk. Ub04 claim form e december 2018 3 ub04 claim form description the ub04 claim form is used to request reimbursement for services rendered by the following institutions. How the ub04 form is used to bill insurance companies by. Ub form billing field descriptions valid claim formats dmap only accepts commerciallyavailable red form versions of the ub04 claim form. For outpatient and other part b services, the upin must be present if the from date is january 1, 1992, or later. Sample ub04 form for inpatient and outpatient services follows as well as a breakdown of each field description and what is required. A new ub04 must be submitted each time there is a break in service. Hicks, phd, mba, is an expert on the health insurance industry with over 15 years of experience in patient financial. Field requirement field name and instructions for ub04 form. The chart of instructions uses color to communicate whether filling in each field on the ub04 claim form is required, not required, required when applicable, or optional when completing a medica.
Patient control number enter your facilitys unique account number. The upin must be present on inpatient part a bills with a through date of january 1, 1992, or later. Claims with missing or invalid required r field information will be rejected or denied. U b 04 the documentation for the ub04 below is relevant to macpractice versions 5. The ub04 manual national uniform billing data element specifications as developed by the national uniform billing committee current revision should be used in conjunction with this provider billing guideline as a reference guide for the preparation of claims to be submitted to nys medicaid. Each form locator has a unique purpose for the insurance carrier and provider so that they can communicate.
Enter the 7digit numeric provider identification number which was assigned by the medicaid program in 57a. The following instructions explain how to complete the ub04 claim form and whether a field is required, required if applicable, or not required. Conditional c fields must be completed if the information applies to the situation or the service provided. An asterisk next to a field indicates that further information is necessary to complete the field e. The chart of instructions uses color to communicate whether filling in each field on the ub04 claim form is required, not required, required when applicable, or optional when completing a medica claim. We will return claims submitted on the ub92 form, blackand.
Overview of the ub04 billing claim form verywell health. Amerihealth insurance company of new jersey qcc insurance company dba amerihealth insurance company. Ub04 billing instructions for long term care claims. Field requirement field name and instructions for ub04 form 1 required billing provider name and address. The ub04 form is popular among all insurance carriers. There are 81 entry fields or boxes on the 837i and cms1450 uniform institutional. Field form locator 43 on the ub 04 in order that this data can be crossed over to medicaid for the billing of medicaid rebates. As mentioned above, the ub 04 form contains more than 80 fields, commonly referred to as form locators, each with its own identifying number. The ub04 claim form accommodates the national provider identifier npi and has incorporated other important changes. Valid claim formats dmap only accepts commerciallyavailable red form versions of the ub04 claim form. Field form locator 43 on the ub04 in order that this data can be crossed over to medicaid for the billing of medicaid rebates. Sample ub 04 forms for inpatient and outpatient claims can be found on pages 4 and 5. The 7digit medicaid provider number previously entered in the ub 92 form locator 51 must be entered here. Ub04 form the uniform bill ub04 is the standardized billing form for institutional services.
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