Ub 04 claim forms may be ordered from the medicaid fiscal agent by. Point of origin codes update to the ub04 cms1450 manual code list national uniform billing committee nubc, will be accepted into the fiscal. Overview of the ub04 billing claim form verywell health. Residential care home services are not covered by masshealth.
Page 1 page 2 table of contents page 3 safety precautions page 4 service precautions page 5 ic removereplacement page 6 specifications page 7 external input format page 8 page 9 adjustment instruction page 10 mac address, esn, widevine, hdcp2. Ub04 stroke is the most common late effectsequela code seen in irfs this table provides a good example of the coding differences on both forms. Ub04 change implementation calendar effective date form locator. Sep, 2017 admission or visit codes to the ub04 cms1450 manual code list. As a result, the nubc introduced several new data elements to the. Medicare replacement pdf download medicare benefits pdf download medicare part b pdf download ncd on ub04. The ub 04 claim form and npi the ub 04 claim form is used exclusively for institutional billing and includes several fields that accommodate the use of your npi, taxonomy, and other provider demographic information. In the field column of the table below, some field numbers are preceded with an asterisk. The next section will provide detailed instructions and descriptions on the ub04 form. Medicare billing form cms1450 and the 837 institutional. Forwardhealth provider portal institutional claims user guide. For specific claim completion instructions, refer to. Although developed by the centers for medicare and medicaid cms, the form has become the standard form used by all insurance carriers.
Forwardhealth provider portal institutional claims user guide june 4, 2019 3 submit an institutional claim 8 when entering a partial description, use the percent symbol % as a wildcard search character on either side of a word or group of words to display all codes containing that word. For public health datareporting only when required by state or federal law or regulations. For a current list of patient status codes, please refer to the nubc ub04 manual. Therefore, the information in this manual is subject to change, and the manual is updated as new billing information is implemented. Sample ub 04 form for inpatient and outpatient services follows as well as a breakdown of each field description and what is. Ub 04 instructions ub 04 instructions page 1 of 11 revised 11. The chars procedure manual and chars companion guide supplement the national uniform billing committee uniform billing form 2004 nubc ub 04 and the asc x12 standards for electronic data interchange technical report type 3, health care claim. Ub 04 change implementation calendar as of 92519 page 3 of 3 the details of the following changes are contained in the ub 04 manual or in the minutes. 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. This document provides detailed instructions for completing the paper ub04 claim form. Providers should refer to the code of colorado regulations, program rules 10 c. For additional information on the completion of fields, please refer to the nubc official ub 04 data specifications manual.
Ub04 claim form instructions geisinger health plan. Of the health plans participating hospital agreement manual. Health first colorado ub04 inpatient outpatient billing manual. Claim completion requirements, claim information and detailed examples will be discussed for the ub04 claim form required by the medical program. The following instructions explain how to complete the ub04 claim form and whether a field is required, required if applicable, or not required. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual. This section provides procedures and guidelines for claim submission and timeliness except for local educational agency lea providers. Effective january 1, 2014, aprdrg version 30 became the reimbursement methodology for all claims with dates of discharge on or after january 1, 2014. January 2014 update of the hospital outpatient prospective payment system opps. The ub 04 claim form accommodates the national provider identifier npi and has incorporated other important changes. In these fields, use hipaacompliant codes that are current for the dates of service on the claim. Effective june 1, 2015, the department updated the payment methodology to aprdrg version 32 for discharge dates after january 1, 2014. 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.
These instructions are to be supplemented with the information and codes in the uniform billing manual for the ub04. Pay to address pay to address if different than field 1. Cms1450, also known as the ub04, is the standard claim form to 2, and the medicare national coverage determinations ncd. Sample ub 04 forms for inpatient and outpatient claims can be found on pages 3 and 4. 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. It is to be used as a companion to, and not a replacement. The document includes instructions applicable to all hmsa lines of business. 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. Direct data entry dde manual claims correction create augus 25 2014 revise ecembe 11 2019. Below is a link to hmsas interactive version of the ub 04 claim form.
Completing the ub 04 claim form overview introduction this chapter describes how to complete and submit the ub 04 claim form for payment from the florida medicaid program through the medicaid fiscal agent. After you click on create you will be able to create a new ub04 claim. The ub 04 claim form is incorporated by reference in 59g4. Below is a link to hmsas interactive version of the ub04 claim form. Msp claims and adjustments that are allowed to be submitted. A ub04 with field descriptions and instructions is included in the link below. A patient discharge status code is a twodigit code entered into form locator fl 17 on the ub 04 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 ub 04. Address any comments concerning the contents of this manual to. Completing the ub04 claim form guidelines for facility. The chars procedure manual and chars companion guide supplement the national uniform billing committee uniform billing form 2004 nubc ub04 and the asc x12 standards for electronic data interchange technical report type 3, health care claim. Blue cross and blue shield of new mexico offers this guide for completion of the ub 04 form for your patients with blue cross facility coverage. No other publication governmental or privatecommercial can be considered authoritative. Refer to the ub04 manual as appropriate and follow. For information on the ub 04 billing form, or to obtain an official ub 04 data specifications manual.
Ub04 claim form instructions november 18, 2014 nevada medicaid. Premera reference manual premera blue cross 023695 022012 ub04 billing chapter 12 page 1 12 ub04 billing. Adobe reader or another pdf reader application is required to view the form. The ub 04 claim form and npi the ub 04 claim form includes several fields that accommodate the use of your npi. Ub 04 form the uniform bill ub 04 is the standardized billing form for institutional services. Refer to the cif submission and timeliness instructions section of this manual for more information. Nov 18, 2014 fields marked required in the ub04 claim form instructions are patient control number.
Please note that providers may not submit claims on printouts of the interactive form. Residential care home billing guide for the ub04 january 2014 page 1 introduction residential care homes choosing to submit their claims on paper must use the ub04 claim form to submit their claims. 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. This manual, ed by the american hospital association, is the only official source of ub data.
Highmark provider manual sample ub04 claim form created date. These instructions are to be supplemented with the information and codes in the uniform billing manual for the ub 04. Patient control number enter your facilitys unique account number. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. Ub04 claim form instructions form locator name instructions 1. This chapter supplements information contained within previous chapters of this manual. This chapter contains participation, claims and billing information for providers who bill on a ub04 cms 1450 claim form. Module objectives identify the section in the provider manual related to ub04 claim form completion. This is an addendum to the national uniform billing committees ub04 data notice writing samples pdf specifications manual, available at. 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. Health first colorado ub04 inpatientoutpatient billing manual. The following instructions explain how to complete the ub 04 claim form and whether a field is required, required if applicable, or not required.
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