A guide for completing the ub 04 form the uniform bill ub 04 is the standardized billing form for institutional services. This is an addendum to the national uniform billing committees ub04 data specifications manual, available at. Please use the national ub 04 manual for specific codes. The 2021 edition contains the updated specifications for the data codes included on the uniform bill claim form. The official ub 04 data specifications manual 2020, ed by the american hospital association, is the only official source of ub 04 billing information adopted by the national uniform billing committee nubc. For more information regarding the tpa, refer to section 3 of this manual. The document includes instructions applicable to all hmsa lines of business. Billing rules, of the feefor service provider billing manual and the appropriate.
Dec 7, 2015 6 a sample ub04 form is available on page 18 of cms pub 4 medicare 20 wcio workers compensation data specifications manual. The displayed claim form is a sample and the information it contains is for illustration purposes only. No other publication governmental or privatecommercial can be considered authoritative. National uniform billing committee official data specifications manual. The following changes apply to ub 04 hospital billing for inpatient admissions and outpatient services. 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. Ub 04 instructions the blocks divided into rows a, b, c reflect the following. Sample ub 04 forms for inpatient and outpatient claims can be found on pages 3 and 4. Medicare part a and part b claims should include the from and.
Please refer to section 2 of this manual for instructions regarding billing procedures for dually eligible beneficiaries. This section contains medicare requirements for use of codes maintained by the nubc. Use the birthdate that appears on the eligibility verification. We strive to deliver highquality, affordable and reliable form filler software products that will increase the efficiency of your claim filing and ultimately your business. Adobe reader or another pdf reader application is required to view the form. To view a sample lthhcp ub 04 claim form, see appendix a. Prints cms1450 ub04 forms on plain paper or preprinted forms. Wisconsin medicaid will continue to accept the ub 92. The two most common claim forms are the cms 1500 and the ub 04.
August 2015, effective november 15, 2015 july 31, 2016 b. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. These instructions are to be supplemented with the information and codes in the uniform billing manual for the ub 04. Health first colorado ub04 hospice care billing manual. Web portal and ub04 institutional claim formats for clients medical care and treatment. Provider handbook 837 institutional ub 04 claim form ub 04 billing guide for promise inpatient hospitals provider handbook ub 04 july 12, 2018 8 form locator number form locator name form locator code notes for a complete listing and description of condition codes, please refer to the ub 04. R3435cp 12312015 clarification on patients reason for visit. Masshealth billing guide for the ub04 executive office of. Uniform claims and billing form reporting manual december 2019 page 6 of 187 inpatient ub 04 data reporting data element description field number ub 04 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. The national uniform billing committee nubc approved the ub 04 as the replacement for the ub 92 at its february 2005 meeting. No other publicationgovernmental or privatecommercialcan be considered authoritative. In this section, you will find the codes we accept on the ub04 claim form.
Billing and policy manual ub04 claim instructions updated august 19 page 1 ub04 claim instructions. Below is a link to hmsas interactive version of the ub04 claim form. The displayed claim form is a sample and is for illustration purposes only. The nubc is responsible for the design and printing of the ub 04 form. Ub 04 and cms1500, attach supporting documentation, query medicaid eligibility. For information on the ub 04 billing form, or to obtain an official ub 04 data specifications manual, visit the national uniform billing committee nubc web site at. Inpatientoutpatient hospital billing manual colorado.
A sample of the back of the form is shown on the next page. New ub 04 claim form completion instructions providers should use the instructions in attachment 1. The ub04 is a uniform institutional bill suitable for use in billing multiple third party liability tpl payers. If sterilization is performed in conjunction with the delivery. The national uniform billing committee nubc maintains lists of approved coding for the form. On a noncolor printout, required fields will appear darkest. To view a sample hcbs waiver ub 04 claim form, see appendix a.
The next section will provide detailed instructions and descriptions on the ub04 form. Uniform claims and billing form reporting manual december 2019 page 7 of 182 ambulatoryoutpatient ub 04 data reporting data element description field number ub 04 form locator page number payto address 2b 44 payto city, state, zip code 2c12c3 45 payto name 2a 43 point of origin for admission or visit 15 69. For a complete code set of services, along with their eligible place of service and modifiers, that can be billed as telehealth please visit the ahcccs medical coding resources web page at. Providers to finish recredentialing in the future cycle in prism. Telehealth billing ffs providers coding providers should follow national coding standards when using hcpcs, cpt and ub 04 revenue codes. This form, also known as the ub04, is a uniform institutional provider bill suitable for.
General prior authorization requirements prior authorization requests pars must be submitted via the coloradopar program. All the fields on this form must be completed in order to process your claim in a timely manner. Ub 04 billing guide for promise icfmr, icforcs and state mr centers purpose of the document document format. Health first colorado ub04 inpatient outpatient billing. Identify the section in the provider manual related to ub04 claim form completion. 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 following instructions explain how to complete the ub 04 claim form and whether a field is required, required if applicable, or not required. Health first colorado ub04 inpatient outpatient billing manual. Ub04 billing instructions guide health pasonline maine.
The uniform bill for institutional providers is the ub04. Following these samples are instructions for completing each field on the ub 04 claim form. Ub 92 billing module august 2003 2 basic rules instructions for completing the ub 92 claim form are included on the following pages. The ub04 manual national uniform billing data element specifications as. New ub04 cms 1450 claim instructions for personal care. Feeforservice provider billing manual reimbursement for the emergency room, observation and other outpatient hospital services provided before the hospital admission are included in the admission and will be paid using inpatient methodology only. This manual contains the updated specifications for the data elements and codes included on the cms1450 and used in the 837i transaction standard. The purpose of this document is to provide a blockbyblock reference guide to assist the following provider types in successfully completing the ub 04.
These instructions are to be supplemented with the information and codes in the uniform billing manual for the ub04. Billing basics e december 2018 1 ub 04 claim form introduction purpose the purpose of this module is to provide participants with detailed information about the completion of the ub 04 claim form for medical services. Workers data from carriers via edi transmission of the cms 1500 claim forms and ub. Due to the icd9icd10 change, services with dates prior to 1001 2015 must be billed on separate claims from services with dates 1001 2015 and later. 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. Note special billing instructions for inpatient services section january 2019. Hcbs waiver providers who choose to submit their claims on paper forms must use the national uniform billing committee nubc ub 04 claim form.
Inpatient services in the part 2 inpatient services manual for billing instructions for ser. Section 1 cms1500 paper claim billing instructionsfield locators multiple page claims when billing a multiple page claim, you must indicate page x of y in box 19, local use of the. 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. Claims with type of bill 011x, 018x, 021x, or 032x are exempt from this rule. The ub 04 contains a number of improvements that resulted from nearly four years of research, and it will better align the hardcopy claim form with. The ub 04 claim form accommodates the national provider identifier npi and has incorporated other important changes. Health first colorado ub04 home health billing manual. Icn 006926 june 2018 additional information is available to subscribers of the nubc official ub 04 data specifications manual. 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. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual. Ub 04 cms 1450 is a claim form used by hospitals, nursing facilities, in patient, and other.
Longterm home health pars that are submitted more than ten 10 business days from the start date. When an outpatient hospital stay crosses two months and the patient is only eligible for medicaid. All claims sent in after june 1, 2015, and with dates of service on or after january 1, 2014. General provider information manual for general billing information. The following is a locator by locator explanation of how to prepare a ub 04 claim form when the recipient has no other insurance or medicare coverage. Unless otherwise noted, all data form locators on the ub 04 have the same attributes specifications for health first colorado as those indicated in the nubcub 04 reference manual. This document will give you instructions, detailing each specific form field. Official ub04 data specifications manual, which is available for the claim and attachments entry menu screen map 1703 appears. Contact your provider network consultant if you have questions about submitting claims electronically. Therefore, the information in this manual is subject to change, and the manual is updated as new billing information is implemented. 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. To view a sample hospice ub 04 claim form, see appendix a. Overview of the ub04 billing claim form verywell health. There are some basic rules you must know before you complete the claim form.
The instructions below are a tool to assist providers with correctly submitting claims to alaska. The national uniform billing committee nubc makes their ub 04 manual available through their website. Hospice providers who choose to submit their claims on paper forms must use the national uniform billing committee nubc standard ub 04 claim form. 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. Hospital billing overview the ohio department of medicaid odm hospital billing guidelines contain basic billing information for ohio medicaid hospital providers regarding inpatient and outpatient claims. The billing agents tpa must include the providers name and medicaid number. The following instructions explain how to complete the ub04 claim form and whether a field is required, required if applicable, or not required. It is intended to be a su pplemental guide to assist providers with specific medicaid policy from a billing.
All institutional paper claims must be submitted using the ub04 claim form. Had selfcare training is a renal dialysis patient and you are billing for special ub04 data spec manual. For inpatient admissions icd10 cm diagnosis and surgical procedure codes will be required for discharges on or after october 1, 2015. 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. The official source of ub 04 billing information adopted by the national uniform billing committee nubc. The ub 04 is a claim form that is utilized for hospital services and select residential services. Submission of a paper ub 04 should be an exception. Address any comments concerning the contents of this manual to. Atypical providers are providers who do not provide medical service and therefore are exempt from obtaining and billing with a npi. Apr 1, 2015 contextsensitive popup selection list speeds claim entry and promotes accuracy. Oct 1, 2015 a complete document containing all current ub04. Audiology billing manual or the laboratory billing manual under cms 1500 for more information. Refer to the billing guidance section for specific billing instructions.
To view the ub04 claim form, click on the link provided below. Macs may include a crosswalk between the asc x12n 837i and the cms1450 on their websites. Pers ub04 billing guidelines version 2009 1 100109 page 10 of 47 paper claims pers providers who choose to submit their claims on paper forms must use the centers for medicare and medicaid services cms standard ub04 claim form. Special instructions for labor and delivery claims delivery is a benefit for recipients of emergency medicaid, but sterilization is not a covered service for recipients of emergency medicaid.
Making copies or utilizing the content of the ub 04 manual, including the codes andor descriptions, for internal purposes, resale andor to be used in any product or publication. All other providers are required to bill with their npi. Please note that these instructions are specifically written to correlate with partners behavioral health managements claim. 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. Anthem blue cross and blue shield provider and facility manual. Health first colorado ub04 inpatientoutpatient billing manual. Medicaid will begin accepting icd10 diagnosis and surgical procedure codes on october 1, 2015. Medicare billing form cms1450 and the 837 institutional. This form, also known as the ub 04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. Location of the arbitration the arbitration hearing will be held in the city and state in which the anthem office identified in the address block on the signature page to the agreement is located. This manual, ed by the american hospital association, is the only official source of ub data. 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. You may like medicare ub04 other ub04 value code g8 no pay bill ub04 medicare ub04 other codes. Hospitals must use appropriate tob when billing for serious reportable events.
A primary payer b secondary payer c tertiary payer. Pers ub04 billing guidelines version 2009 1 100109 page 3 of 47 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. Because it serves many payers, a particular payer may not need some data elements. Pdf or paper statement issued by emedny that contains the status of claim. Claim completion requirements, claim information and detailed examples will be discussed for the ub 04. 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. Please consult the general provider information manual on the departments billing manual web page for information about prior authorization requirements. 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.
New elevation in troponin greater than three times upper level of the reference range in the setting of. It will also explain how to process the hcfa1500 cms 1500 medical form. Please note that providers may not submit claims on printouts of the interactive form. Claims and attachments menu cgs apr 4, 2015 their contents. Medicare claims processing manual chapter 3 inpatient hospital billing. Created as an adobe portable document file pdf that allows users to print or.
Hca inpatient and outpatient revenue code grid effective july 2015. The ub 04 claim form and npi the ub 04 claim form includes several fields that accommodate the use of your npi. Blue cross and blue shield of oklahoma offers this guide to help you complete the ub 04 form for your patients with. Pennsylvania promise provider handbook 837 institutionalub04 claim form october 2017, version 2. Anthem blue cross and blue shield provider manual nv page 10 of 190 revised. Instructions for completing the ub 04 claim form are based on the current national uniform billing committee nubc ub 04 reference manual. Billing and policy manual ub 04 crossover claim updated august 19 page 1 ub 04 medicare crossover claim instructions. Providers should refer to the code of colorado regulations, program rules 10 c. Health first colorado ub04 inpatientoutpatient billing. After you click on create you will be able to create a new ub04 claim. 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 governmental initiatives. Inpatient hospital facilities, such as medicalsurgical intensive care, burn care, coronary care and ancillary charges such as labor and delivery, anesthesiology and.
A guide for completing the ub04 form blue cross blue. The following is a locator by locator explanation of how to prepare a ub 04 if you have received your medicare eob more than 30 days ago and a remittance advice from medicaid does. The ub04 claim form is used to bill for all hospital inpatient, outpatient, and emergency. Chapter 6 snf inpatient part a billing and snf consolidated billing.
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