Billing guide for the ub04 february 2021 page 4 how to complete the ub04 claim form a sample of the front of the ub04 claim form is shown below. Hospital ub04 claim filing instructions, section 2. Ub04 special billing instructions for inpatient services ub. The ub04 claim form accommodates the national provider identifier npi and has incorporated other important changes. The allowed values for each of the digits found in the type of bill are listed below. September 2020 ub04 claim form description the ub04 claim form is used to request reimbursement for services rendered by the following institutions. The multiple pages should be attached to each other. Handbook for hospital billing, with answer key, print edition. You can access the ub04 billing information adopted by the nubc by subscribing. Please make this manual available to providers, their billing staffs and billing entities.
Form locator 16 dhr not required form locator 17 patient discharge status enter the code indicating disposition or discharge status of the member at the end service for the period covered on this claim. A sample of the back of the form is shown on the next pa ge. These instructions are to be supplemented with the information and codes in the uniform billing manual for the ub04. Charlotte, augusta and savannah are considered within the service area. Cesarean delivery of acutely sick baby figures 1a and 1b. Ub04 billing guide for promise nursing facilities for. Modifier tc on ub04 form outpatient hospital billing. It contains updated specifications for the data elements and codes included. Ub 04 claim form instructions ak provider billing manuals.
The sum of the days reported in the following fields. May 03, 2017 electronic ub 04 claims must be submitted in a format that is hipaa compliant with the ansi x 12 ub04 claim standards. Refer to the billing guidance section for specific billing instructions. Please note that ndc codes are also required on these claims. Patient control number enter your facilitys unique account number. Completing the ub04 claim form guidelines for facility.
Submitting the claim form with all required fields will assist us in paying your claim in a timely manner. Nonpayment for wrong surgical events for all hospital providers. Mississippi medicaid provider billing handbook section. Mail cms1500, ub04 and ada paper claims, adjustments and voids to. Uniform claims and billing form reporting manual november 2020 page 6 of 187 inpatient ub04 data reporting data element description field number ub04 form locator page number payto address 2b 45 payto city, state, zip code 2c12c3 46 payto name 2a 44 point of origin for admission or visit 15 71 principal diagnosis code 671 123. Medical reference manual ub04 billing premera blue cross. The national uniform billing committee nubc maintains lists of approved coding for the form. A grouper program assigns an apr drg by utilizing data submitted on the claim such as icd9cm diagnoses, procedures, member age, sex, and other. All institutional paper claims must be submitted using the ub04 claim form. Emedny information inpatient hospital version 2011 01 612011. Trillium only accepts the cms 1500 212 and cms 1450 ub 04 paper claim forms. Because it serves many payers, a particular payer may not need some data elements. Ub04 cms 1450 billing guidelines the centers for medicare and medicaid services cms form 1450, referred to as the ub04, is the standard claim form used to bill facility services to us and our affiliates. Hospital ub04 claim filing instructions, section 2 billing book.
This form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. The nonroutine laboratory services must be billed under the independent. When billing for multiple dates of service, enter the first service date of the billing period in the from box and. In 2007, a nationwide change from the ub92 form for hospital claims billing to the ub04 form occurred. Ub04 billing provider premera blue cross blue shield of. Handbook for hospital billing, with answer key, print. Ub04 billing instructions partners provider knowledge base. Please refer to the provider administrative and billing manual, requirements for provider participation, for instructions regarding provider enrollment. Instructions for completing the ub04 claim form are based on the current national uniform billing committee nubc ub04 reference manual. The american hospital association holds the to the official ub04 data specifications manual, which includes information adopted by. The following is a locator by locator explanation of how to prepare a ub04 if you have received your.
No other publicationgovernmental or privatecommercialcan be considered authoritative. The national ub04 uniform billing manual contains important coding information not. The office of management and budget and the national uniform billing committee have approved the ub04 claim form, also known as the cms1450 form. Cesarean delivery, acutely sick baby in contract ob per diem hospital. 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. Separate claim forms must be prepared for a hospital stay. Ub04 cms 1450 claim form instructions for outpatient.
Ub04 hospital billing instructions maryland medicaid maryland. Billing and policy manual ub04 long term care updated february 21 page 1 ub04 longterm care claim instructions. When submitting the above claims, complete all items required by each payer who is to receive a copy of the. Ub04 billing instructions partners health management. Inpatient services in the part 2 inpatient services manual for billing instructions for services rendered to a registered hospital inpatient. The reporting of claims billing data from tennessee hospitals to the alsotdh changed at. Another example appears at the end of this presentation. It is to be used as a companion to, and not a replacement. New york state medicaid update july 2019 volume 35 number 8. A freestanding dialysis center that performs its own laboratory tests must be licensed as an independent clinical laboratory and enrolled in the health first colorado as an independent laboratory.
Oct 23, 2006 crosswalk to old manuals 10 reserved 70 uniform bill form cms1450 ub04 70. The ub04 is a claim form that is utilized for hospital. The communitycare emergency indicator was formerly entered in ub92 form locator 11. Billing and policy manual ub04 claim instructions updated december 20 2 831 outpatient hospital surgical procedures, admission through discharge. The ub04 paper claim form should be legibly printed by hand or electronically. Ub04 billing form the information listed below are the ub04 fields that must be completed accurately and completely in order to avoid claim suspense or denial. Please note that these instructions are specifically written to. Inside is a blank ub04 claim form for reference, and information on medica s requirements for successful completion of the ub04 claim form. See instructions for field 43 in the how to complete the ub04 claim form section in this guide. Ub04 billing provider premera blue cross blue shield. Outofstate services the term scmsa refers to the state of south carolina and areas in north carolina and georgia within 25 miles of the south carolina state border. Standard option method 1 professional fees billed to medicare part b on a cms1500 claim form.
The official ub04 data specifications manual 2021, ed by the american hospital association, is the only official source of ub04 billing information adopted by the national uniform billing committee nubc. The ub04 is a uniform institutional bill suitable for use in billing multiple third party liability tpl payers. Cms iom, publication 4, medicare claims processing manual, chapter 4, section 250. The national uniform billing committee nubc maintains the lists of approved codes for the form. 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. Hospitals billing for services associated with low level emergency physician care 99281, 99282 should place a 1. Subscription information nubc, ub04, hospital billing.
If providers do not use the emergency indicator correctly, the claim will deny with a 104 error edit. The format of this 3 character code is indicated below. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. Billing manuals colorado department of health care. Refer to the ub04 billing manual for more information. For example, if there was no 3day prior hospital stay, enter no 3day prior hospital stay. Hospital resulting in a separate claim to the payer. Ub04 billing examples for inpatient services page updated. The following is a locator by locator explanation of how to prepare a ub04 claim form when the recipient in a longterm care facility. These instructions are for the completion of the ub04 claim for forwardhealth.
The ub04 is a claim form that is utilized for hospital services and select residential services. Type of bill m a ub04 claim form may be used to bill for longterm care or to replace a claim for long term care that was paid by ma. Completion of ub04 for hospital inpatientoutpatient services the uniform bill for institutional providers is the ub04 cms1450. This is the example of the ub04 form discussed here. This manual, ed by the american hospital association, is the only official source of ub data. Ub04 cms 1450 claim form instructions for inpatient. Ub04 cms 1450 claim form instructions for inpatient hospital services. Other claim form types will be rejected and returned to the provider. Ub04 claim form instructions the following rules for the ub04 are excerpts from medicare instructions, but they are generally universal for billing specially designated facilities.
Mo healthnet paper claims for hospital inpatient care are mailed to. All other form locators of the ub04 must be completed as per the billing guide. August 2020 split billing a hospital stay the following policy pertains to hospitals reimbursed according to drgreimbursed or nondrg reimbursed methods, as indicated. Part 2 ub04 special billing instructions for inpatient services page updated. Two previously collected fields are not on the new form and are dropped from reporting. For status codes, please refer to the nubc ub04 manual. Ub04 claim form instructions form locator name instructions 1. Inpatient hospital facilities, such as medicalsurgical intensive care, burn care. The instructions are organized by the corresponding boxes.
The instructions are organized by the corresponding boxes or form locators on the paper ub04 and detail. Please note that these instructions are specifically written to correlate with partners behavioral health managements claim management system alpha mcs. 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. Pay to address pay to address if different than field 1. A hospital is defined as a general acute care institution licensed as a hospital by the applicable. Medical billing training do ascs use cms 1500 or ub 04 forms billing course alicia. Unless otherwise noted, all data form locators on the ub04 have the same attributes specifications for the health first colorado as those indicated in the nubcub04 reference manual. The uniform bill for institutional providers is the ub04. Separate claim forms must be prepared for a hospital. No other publication governmental or privatecommercial can be considered authoritative. Dialysis billing manual 820 federally qualified health centerrural health center fqhcrhc.
Ub04 special billing instructions for inpatient services. For complete billing instructions, refer to the national ub04 uniform billing manual prepared by the nubc. The following instructions explain how to complete the ub04 claim form and whether a field is required, required if applicable, or not required. Consult with your specific insurance payer for their adaptations. This manual, ed by the american hospital association, is the only. Billing and policy manual ub04 crossover claim updated december 20 page 1 ub04 medicare crossover claim instructions. In most cases, professional providers and medical suppliers complete the cms 1500 212 form and institutional providers complete the cms 1450 ub 04 claim form.
Ip and op hospital billing manual 920 nursing facility billing manual 820 private duty nursing billing manual 820 psychiatric residential treatment facilities prtf billing manual 820 national billing guidelines. Enter the appropriate 3character code to identify the type of bill being submitted. May 16, 2019 providers are reminded that pursuant to the inpatient billing procedures for all patient refined diagnostic related groups apr drgs, documented in emednys new york state ub04 billing guidelines inpatient hospital manual, claims for newborns must accurately contain the newborns birth weight in grams. Enter one of the appropriate codes indicating the priority of this admission. Masshealth billing guide for the ub04 executive office of. This guide gives detailed line by line instructions on how to complete the ub04 claim form. Type of bill must be consistent with services rendered. Overview of the ub04 billing claim form verywell health. National uniform billing committee official data specifications manual. Sample ub04 forms for inpatient and outpatient claims can be found on pages 3.
Ive been involved with hospital billing for 20 years and never encountered a payer that required the tc modifier on a ub04 claim, but if you need an official reference, then id recommend looking for this in the uniform billing editorub04 manual which contains the regulations governing the use of the ub04 form. Section 2 ub04 claim filing instructions november 2012 2. The ub 04 claim form is used to bill for all hospital inpatient, outpatient, and emergency room services. The centers for medicare and medicaid services cms form 1450, referred to as the ub04, is the standard claim form used to bill facility services to us and our affiliates. Be sure to include prior authorization number, timely filing tcn, proper procedure codes, modifiers, units, etc. Inpatient hospital new york state ub04 billing guidelines version 2011 01 612011. Medical billing training do ascs use cms 1500 or ub 04. Following these samples are instructions for completing each field on the ub04 claim form.
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