A sample of the back of the form is shown on the next page. Ub04, inpatient outpatient hospital inpatient and outpatient, hospice nursing home and home services, home health. The official ub04 data specifications manual 2020 is the source of ub04 billing information adopted by the national uniform billing committee nubc. Long term care providers private daily room rate form ub04 billing. Billing guide for the ub 04 september 2015 page 4 how to complete the ub 04 claim form a sample of the front of the ub 04 claim form is shown below. Pennsylvania uniform billing form reporting manual for ambulatoryoutpatient facilities 3 pennsylvania health care cost containment council revised may 2015 data element description field number ub 04 form locator page number accident state 29 71 admission hour 64 admissionstart of care date 12 63 admitting diagnosis code 69 122. This form, also known as the ub04, is a uniform institutional provider bill suitable for trail purposes and be able to pass coordination of benefits data to other payers this section contains medicare requirements for use of codes. Enter the name, address, and louisiana medicaid id of the provider if. These instructions are to be supplemented with the information and. Inpatient services billing example inpatient services. Sample ub 04 forms for inpatient and outpatient claims can be found on pages 4 and 5.
Longterm home health pars that are submitted more than ten 10 business days from the start date. Pay to address pay to address if different than field 1. If providers do not use the emergency indicator correctly, the claim will deny with edit 104. Cms 1500 claim form and ub 04 form instruction and guide. On a noncolor printout, required fields will appear darkest. You may like medicare ub04 other ub04 value code g8 no pay bill ub04 medicare ub04 other codes.
A patient discharge status code is a twodigit code entered into form locator fl 17 on the ub04 claim form that identifies the patients status at the conclusion of a health care facility encounter this could be a visit or an actual inpatient stay or at the time end of a billing cycle the through date of a claim found in fl 6 on the ub04. Chapter 25 completing and processing the form cms1450 data set. The ub 04 claim form is used to submit claims for outpatient services by institutional facilities for example, outpatient departments, rural health clinics and chronic dialysis centers see ub 04 completion. Enter the name, address, and phone number of the provider rendering the service.
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 hospital billing instructions and matric revenue code. All code values listed in the nubc ub04 reference manual for each form locator ub04 claim form medical. The ub 04 cms1450 to submit charges under medicare part a. Ub04 billing instructions for long term care claims. All other providers are required to bill with their npi. The mainecare instructions are adapted from the ub04 manual developed by.
In this section, you will find the codes we accept on the ub04 claim form. The following instructions explain how to complete the ub04 claim form and whether a field is required, required if applicable, or not required. Sample ub04 forms for inpatient and outpatient claims can be found on pages 4 and 5. Provider qualifications providers must be enrolled as a health first colorado colorado s medicaid program provider in order to. Because it serves many payers, a particular payer may not need some data elements. Medicare claims processing manual, chapter 25 pub 4 medicare claims processing. Facility billing policy unitedhealthcare community plan. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual.
Providers to finish recredentialing in the future cycle in prism. New elevation in troponin greater than three times upper level of the reference range in the setting of. Health first colorado ub04 home health billing manual. The following changes apply to ub04 hospital billing for inpatient admissions and discharges on or after october 1, 2015. Hmsa has determined that it will use the national uniform billing committee nubc official ub04 data specifications manual as the standard source for codes and code descriptions to be entered in the various form locators fl. Although developed by the centers for medicare and medicaid cms, the form has become the standard form used by all insurance carriers. Please use the national ub04 manual for specific codes. Admit and publication date of the 2015 ub04 manual.
Instructions and guideline for cms 1500 claim form and ub 04 form. Hospitals billing for services associated with low level emergency physician care 99281, 99282 should place a 1 in form locator 7 on the ub04. Following these samples are instructions for completing each field on the ub 04 claim form. This manual, available by annual subscription license, contains the updated specifications for the data elements codes included on the ub04 uniform bill claim form.
A primary payer b secondary payer c tertiary payer. Completing the ub04 claim form guidelines for facilityinstitutional providers 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. Ambulatory surgical centers florida department of financial. Icn 006926 june 2018 additional information is available to subscribers of the nubc official ub04 data specifications manual. Medicare billing form cms1450 and the 837 institutional. The official ub 04 data specifications manual 2020 is the source of ub 04 billing information adopted by the national uniform billing committee nubc. 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. The ub04 manual national uniform billing data element specifications as. For information regarding the par program including policy and howto guides please visit the. Ub04 billing instructions for hospitals updated june 2019. Ub04 claim form instructions geisinger health plan. Medicare secondary payer msp value codes vc fl 3941. Reaching across arizona to provide comprehensive 3 quality health care for those in need.
Soft edits are performed, no claim denials, for ub04 claims submitted at this time. Field requirement field name and instructions for ub04 form 1 required billing provider name and address. The ub04 is a claim form that is utilized for hospital services and select residential services. Health first colorado ub04 inpatientoutpatient billing manual. Billing rules, of the feefor service provider billing manual and the appropriate. After you click on create you will be able to create a new ub04 claim. Ub 04 instructions the blocks divided into rows a, b, c reflect the following. Inpatient services billing example inpatient services 492. Providers should refer to the code of colorado regulations, program rules 10 c. All institutional claims submitted on behalf of medicare patients must be in the cms1450 ub 04 claim format.
Special instructions and examples for cms1500, ub04 and edi. Please be advised that the west virginia medicaid provider manual does not. The instructions are organized by the corresponding boxes or form locators on the paper ub04 and detail only those data elements required for medical assistance ma paper claim billing. Destination page number search scope search text search scope search text. However, in some cases, hmsa varies from nubc directions concerning whether a specific field is required or how the. This section illustrates billing examples of medicaremedi cal crossover claims for part b services billed to part a contractors submitted hard copy on a ub04 claim form and correlating remittance advice ra examples. Enter the name and address of the billing provider. Inpatient services in the part 2 inpatient services manual for billing instructions for ser. Overview of the ub04 billing claim form verywell health. The following changes apply to ub 04 hospital billing for.
In addition to the national ub04 manual, in order to complete the ub04 form, utilize the current cpt current procedural terminology of the american medical association, the current icd international classification of diseases diagnostic codes based on date of service, or hcpcs healthcare common procedure coding system codes maintained by the centers for medicare and medicaid services. The purpose of this document is to assist the provider community in understanding and complying with the new york state medicaid nys medicaid requirements and expectations for. See instructions for billing no part a at the end of the ub billing instructions. A national coverage determination ncd that allows payment of routine itemsservices, and payment of the investigational itemservice if it is normally covered outside of the trial and meets medical necessity. Following these samples are instructions for completing each field on the ub04 claim form. Inpatient services section of this manual for instructions to complete claim fields. Enter the name and address of the facility 2 pay to nameaddressid situational. Fl 01 billing provider name, address and telephone number 11 11. Refer to the following resource for guidelines on completing the ub04. Soft edits are performed, no claim denials, for ub 04 claims submitted at this time.
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. Pennsylvania promise provider handbook 837 institutionalub. Pennsylvania uniform billing form reporting manual for inpatient facilities 2 pennsylvania health care cost containment council revised may 2015 data element description field number ub04 form locator page number accident state 29 72 admission hour 64 admissionstart of care date 12 62 admitting diagnosis code 69 125. Completing the ub04 claim form guidelines for facility. Proprietary information of unitedhealthcare community plan. The ub04 claim form is used to submit claims for outpatient services by institutional facilities for example, outpatient departments, rural health clinics and chronic dialysis centers see ub04 completion. The ub04 cms1450 to submit charges under medicare part a. Masshealth billing guide for the ub04 executive office of. Transmittals for this form, also known as the ub04, is a uniform institutional provider bill suitable for. Billing instructions can be found on the molina medicaid solutions website at. Enter the fourdigit code from the national ub04 manual for the provider type that indicates the type of bill using the following guidance by provider type. For complete information regarding ub04 coding please refer to.
For electronic billing, please refer to the maryland medicaid 837i electronic companion guide, which can be found on our website. Although not required, you can use this field to enter the recipients unique control. Description accessible from the national uniform billing committee nubc official ub04. Dec 4, 2018 identify the section in the provider manual related to ub04 claim form completion icd10cm diagnosis codes and icd10 pcs codes on a claim to ensure payment at the nubc ub04 data specifications manual. Official ub04 data specifications manual 2020 authors. Health first colorado ub04 inpatientoutpatient billing. This form, also known as the ub04, is a uniform institutional provider bill suitable for. Pennsylvania uniform billing form reporting manual for inpatient facilities 2 pennsylvania health care cost containment council revised may 2015 data element description field number ub 04 form locator page number accident state 29 72 admission hour 64 admissionstart of care date 12 62 admitting diagnosis code 69 125. Enter the fourdigit code from the national ub 04 manual for the provider type that indicates the type of bill using the following guidance by provider type. The cms claims processing manual, pub 100 04, chapter 25 contains general instructions for completing the cms1450 for billing. 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. Clinical trials coverage and billing guide noridian. Hospitals must use appropriate tob when billing for serious reportable events.
The following changes apply to ub04 hospital billing for. Icn 006926 june 2018 additional information is available to subscribers of the nubc official ub 04 data specifications manual. Completion of cms1450 ub04 claim form to part a claims center. Fl 01 billing provider name, address and telephone number p. Medicare claims processing manual crosswalk centers for cms1450 data set.
Personal care services ub04 billing guidelines version 2007 1 012507 page 3 of 49 section i purpose statement the purpose of this document is to assist the provider community in understanding and complying with the new york state medicaid nys medicaid requirements and expectations for. The inpatient revenue code claim line best practice billing is to complete a single claim line with the first date of service of the stay and or portion of the stay for interim bills in ub04 box 45. All requirements will be enforced on january 1, 2015. Ub04 claim form and instructions independence blue cross. Therefore, the information in this manual is subject to change, and the manual is updated as new billing information is implemented. Billing rules, of the feeforservice provider billing manual and the appropriate. Failure to comply could result in claim rejections. However, in some cases, hmsa varies from nubc directions concerning whether a specific field is required or how the data is to be entered in a specific field. No other publication governmental or privatecommercial can be considered authoritative. Pennsylvania uniform billing form reporting manual for ambulatoryoutpatient facilities 3 pennsylvania health care cost containment council revised may 2015 data element description field number ub04 form locator page number accident state 29 71 admission hour 64 admissionstart of care date 12 63 admitting diagnosis code 69 122. This authorization is for the institutional claim ub04. These instructions are to be supplemented with the information and codes in the uniform billing manual for the ub04. Ub04 billing instructions guide health pasonline maine. Official ub04 data specifications manual 2020 page 5.
Medicaid will begin accepting icd10 diagnosis and surgical procedure codes on october 1, 2015. The following changes apply to ub 04 hospital billing for inpatient admissions and outpatient services. This manual, available by annual subscription license, contains the updated specifications for the data elements codes included on the ub 04 uniform bill claim form. Provider claims and billing manual amerihealth caritas district of. Chapter 509 hospice services effective june 1, 2015. Please note that these instructions are specifically written to correlate with partners behavioral health managements claim. Covered days are reported in the value code field 39 41 as value code 80. The hcfa1500 form cms1500 is used to submit charges covered under medicare part b.
Address any comments concerning the contents of this manual to. The ub04 claim form is used to bill for all hospital inpatient, outpatient, and emergency. Patients relationship to insured see the ub04 manual for the 2digit. For inpatient admissions icd10 cm diagnosis and surgical procedure codes will be required for discharges on or after october 1, 2015. The next section will provide detailed instructions and descriptions on the ub04 form.
Official ub04 data specifications manual 2020 page 4. Does a hospital need to purchase the 3m coding module for eapg billing in order to be you will continue to bill services on the ub04 claim form or using the 837 health visits unless certain revenue codes e. The national uniform billing committee nubc maintains lists of approved coding for the form. R3435cp 12312015 clarification on patients reason for visit.
Had selfcare training is a renal dialysis patient and you are billing for special ub04 data spec manual. Billing guide for the ub04 september 2015 page 4 how to complete the ub04 claim form a sample of the front of the ub04 claim form is shown below. For a current list of patient status codes, please refer to the nubc ub04 manual. Introduce general completion and submission billing guidelines for the ub04 claim form. Please use the national ub 04 manual for specific codes. Ub04 claim form instructions form locator name instructions 1. Atypical providers are providers who do not provide medical service and therefore are exempt from obtaining and billing with a npi. Identify the section in the provider manual related to ub04 claim form. Hmsa has determined that it will use the national uniform billing committee nubc official ub 04 data specifications manual as the standard source for codes and code descriptions to be entered in the various form locators fl. This manual, ed by the american hospital association, is the only official source of ub data. Professional claims cms 1500 associated with the admission may need authorization separately depending on the service. Centers for medicare and medicaid services cms or other coding guidelines.
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