Ub04 claim form, also known as the cms1450 form, for facility and sample ub04 forms for. A guide for completing the ub04 form blue cross and. Shield of texas offers this guide to help you complete the ub04 form for your patients with blue cross facility coverage. Indiana health coverage programs updated ub04 paper claim form requirements provider bulletin bt200702 january 30, 2007 ub 04 claim form requirements this section provides a brief overview of the changes required for completion of the ub 04 claim form.
R2683cp 040520 nonsystems internet only manual iom. Fl 10 lifetime reserve days converted to value code codes that do not fit into other fields. Premera reference manual premera blue cross 023695 022012 ub04 billing chapter 12 page 1 12 ub04 billing. Shield of texas offers this guide to help you complete the ub 04 form for your patients with blue cross facility coverage. Chapter 25 completing and processing the form cms1450 data set. These values are valid for paper claim subm ssion on the ub04 claim form only. Valid codes now include all codes listed in the most current nubc official ub04 specifications manual. To obtain a copy of the nubc ub04 manual, please visit. Any other material was previously published and remains unchanged. Indiana health coverage programs updated ub04 paper claim form requirements provider bulletin bt200702 january 30, 2007 ub04 claim form requirements this section provides a brief overview of the changes required for completion of the ub04 claim form. Ub92 desk reference these values are valid for paper claim subm ssion on the ub04 claim form only.
It is to be used as a companion to, and not a replacement. Sep 17, 20 ub04 claim form instructions may 14, 20 nevada medicaid may 14, 20 updated. This form, also known as the ub04, is a uniform institutional provider. To license the electronic data file of ub04 data specifications, contact tim carlson at 312 8936816. The data for the hpr, obtained from the ub04 uniform billing form, was submitted electronically to the pennsylvania health care cost containment council by pennsylvania phc4 hospital performance report cy 20 data technical notes. Ub04 billing instructions guide health pasonline maine. The ub 04 data specifications manual is the official source of data specifications adopted by the nubc and contains codes used in the 837 institutional electronic claims. To license the electronic data file of ub 04 data specifications, contact tim carlson at 312 8936816. 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.
This value or value 58 is required on the initial bill for oxygen therapy and on the fourth months bill. Wisconsin medicaid will continue to accept the ub92. Chars procedure manual washington state department of. For a detailed billing example that outlines possible billing scenarios, please go. This manual, ed by the american hospital association, is the only. Astcodc data system user manual january 2020 7 changes in the manual from 20 through 2018 continued.
Home health 2digit patient status code, as follows. Cms will not pay the ccmcc drg for those selected hacs that are coded as 1 for the poa indicator. We are recommending using the references distributed by the national uniform billing committee nubc official ub04 data specifications manual. Tob values must be submitted on the ub04 cms1450 claim form or electronic equivalent in accordance. Please see the national ub04 manual for complete instructions and specific codes. Aug 19, 20 the ub04 is the basic hardcopy form and is also known as the form cms1450 like its predecessor, the ub92. Since the characters q and z are not available on all touchtone phones, enter the digit 7 for the letter q and. The displayed claim form is a sample and is for illustration purposes only. Ub04 instructions ub04 instructions page 5 of 11 revised 11. Face sheet discharge summary ub04, field locations. Although the form is similar in appearance to the older version of the facility claim form, ub92, a number of fields have been moved or expanded and. 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. New ub04 claim form completion instructions providers should use the instructions in attachment 1.
A guide for completing the ub04 form blue cross blue. The national uniform billing committee nubc makes their ub04 manual available through their website. This manual, ed by the american hospital association, is the only official source of ub data. While vizient data collect similar information as ub 04, patient identifiers are not included, and the dates of the encounter are masked.
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. This chapter contains participation, claims and billing information for providers who bill on a ub04 cms 1450 claim form. Ub04 claim form instructions geisinger health plan. Use this code for services on or before july 31, 20. Unless otherwise noted, all data form locators on the ub04 have the same attributes specifications for the colorado medical assistance program as those indicated in the. B3 benefits ub04 claim form and instructions independence blue cross the ub04 claim form includes several fields that accommodate the use of your npi. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual. Starting may 23, 2007 all institutional paper claims must use the ub04. The hospital reports right justified in the cents area.
Inpatient services in the part 2 inpatient services manual for billing instructions for services rendered to a registered hospital inpatient. The patient status code form locator 17 on the ub04 claim form identifies patient status as of statement covers through date and is required on all institutional inpatient. For information on the ub04 billing form, or to obtain an official ub04 data specifications manual. Please use the following link to read the complete patient discharge status faqs from nubc. Blue cross and blue shield of oklahoma offers this guide to help you complete the ub04 form for your patients with blue cross facility coverage. The ub04 claim form may be used to bill for inpatient hospital care or to replace a claim for inpatient hospital care that was paid ub04 desk reference for long term care facilities. Submit a the claim was submitted with an idrd waiverspecific. Ub 04 form the uniform bill ub 04 is the standardized billing form for institutional services. 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. Review the resolution instructions below for the edit codes that apply to your claim. Jan 07, 2016 the ub 04 data specifications manual is the official source of data specifications adopted by the nubc and contains codes used in the 837 institutional electronic claims. Blue cross and blue shield of new mexico offers this guide for completion of the ub04 form for your patients with blue cross facility coverage. The data for this analysis, obtained from the ub04 uniform billing form, was submitted electronically to phc4 by pennsylvania general and specialty acute care hospitals.
For information on the ub04 billing form, or to obtain an official ub04 data specifications manual, visit the national uniform billing committee nubc web site. The uniform bill ub04 is the standardized billing form for institutional services. Access to information on this site is only allowed for necessary. Number assigned to patients medical record by provider. Jan 05, 2014 ub92 desk reference these values are valid for paper claim subm ssion on the ub04 claim form only. Dataelem0072 manual performance measurement network. 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. Dataelem0075 manual performance measurement network. Ub 04 medicare discharge status code cms 1500 claim form. Enter the name and address of the facility 2 pay to nameaddressid situational. The product of the number of lifetime reserve days used in the second calendar year of the billing period multiplied by the applicable lifetime reserve rate. Influence of concrete strength influence of edge distance influence of spacing valid for a group of two anchors. Kansas workers compensation kansas department of labor.
National uniform billing committee nubc ub04 reference manual. Ub04 claim form instructions may 14, 20 nevada medicaid may 14, 20 updated. For part b coinsurance use value codes a2, b2 and c2. Patient status code 08 dischargetransfer to home care of home iv provider is no longer valid. Use the ub 04 data specifications manual and the icd10cm official guidelines for coding and reporting to facilitate the assignment of the poa indicator for each principal diagnosis and other diagnoses codes reported on claim forms ub 04 and 837 institutional. Ub04 instructions for hospitals louisiana medicaid.
We are recommending using the references distributed by the national uniform billing committee nubc official ub 04 data specifications manual. Medicare lifetime reserve amount in the second calendar year in billing period. Macs may include a crosswalk between the asc x12n 837i and the cms1450 on their websites. Blue cross and blue shield of oklahoma offers this guide to help you complete the ub 04 form for your patients with blue cross facility coverage. Effective for services provided onafter january 1, 2016, computed tomography ct imaging furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association nema xr29 20 standard. Immune globulin hcpcs j1575 and associated infusion pump hcpcs e0781 where route of administration is subcutaneous.
Immune globulins hcpcs j1559, j1561, j1562, j1569 and associated infusion pump hcpcs e0779 where route of administration is subcutaneous. Current dental terminology companion, cdt202014, 2012, published by the american dental association. The ub 92 claim form will no longer be accepted after may 22, 2007. This code is equivalent to a blank on the ub04, however. The ub92 claim form will no longer be accepted after may 22, 2007. Ub04 discharge status 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. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. In addition, please refer to appendix c for the codes and values associated with this data element.
Page kn range iii additional hilti technical data not part of eta040027, issue 20626. Standard text characters with ascii values between 32 and 127 are accepted. Effective for services provided onafter january 1, 2016, computed tomography ct imaging furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association nema xr2920 standard. This form, also known as the ub04, is a uniform institutional provider bill. The 202016 nhcs data available in the rdc are based on a sample of 581 hospitals drawn from the universe of eligible hospitals. Loop 2300 dtp03 when dtp01 434 enter the dates of service claimed in accordance with the instructions provided below. The provider uses this code only on bills spanning 2. For information on the ub 04 billing form, or to obtain an official ub 04 data specifications manual. The principal diagnosis is defined in the uniform hospital discharge data set uhdds as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. You can access the ub04 billing information adopted by the nubc by subscribing. This manual contains the updated specifications for the data elements and codes included on the cms1450 and used in the 837i transaction standard. This article includes tables of some of the most common condition, occurrence, value, patient relationship, and remarks field codes associated with msp claims.
No other publication governmental or privatecommercial can be considered authoritative. Bt200702 tr654 updated ub04 paper claim form requirements. Condition, occurrence, value, and patient relationship, and remarks field codes. Inpatient services billing example inpatient services 492. Hospital ub04 claim filing instructions, section 2 billing book. Medicare will only accept codes listed in fields ah. Enter integer values to the left of the dashed line so that no decimal point will be added. These values are valid for paper claim submission on the ub04 claim form only.
Hospital discharge data system user manual august 2018 7 numerous and significant changes have been made to the ub 04 manual from 2011 through 2018. Guide to the ub04 manual this ub04 manual is the official source for ub04 information adopted by the. Enter the name, address, and louisiana medicaid id of the provider if different from the provider. Inpatient services billing example inpatient services 522. To view a sample cmcm ub04 claim form, see appendix a. Form locators 1828 ai sterilization patient consent form ma 31. Some fields have been changed, or codes have been added or deleted for existing fields. In the amount fields, after the appropriate code, enter the amount. Ry2019 eohhs technical specifications manual for masshealth acute 6 table 6. These fields must be completed or the claim is denied. Tips for completing the ub04 cms 1450 claim form page 2 of 17. The data included demographic information, hospital charges, and diagnosis and procedure codes icd9cm. New patient discharge status codes on ub04 claim form.
Ub04 form the uniform bill ub04 is the standardized billing form for institutional services. The ub04 data specifications manual is the official source of data specifications adopted by the nubc and contains codes used in the 837 institutional electronic claims. Reference the official ub04 data specifications manual for valid values. Hospital discharge data system user manual august 2018 7 numerous and significant changes have been made to the ub04 manual from 2011 through 2018. All code values listed in the nubc ub04 reference manual for each form locator ub04 claim form medical. The revision date and transmittal number apply only to red italicized material. January 2020 integrated outpatient code editor ioce. 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. This chapter supplements information contained within previous chapters of this manual.