2014 ub 04 manual for codes

These instructions are to be supplemented with the information and codes in the uniform billing manual for the ub04. Ub 04 claim form instructions the new claim form supports the use dhs. Special instructions for labor and delivery claims delivery is a benefit for recipients of emergency medicaid, but. Form locator number form locator name form locator code notes 8 voidcancel of prior claim. Center for health statistics hospital and patient data systems comprehensive hospital abstract reporting system chars p. Type of bill enter the four digit code that identifies the specific type of bill and frequency of submission. Effective january 28, 2011 revised september21, 20 revised january 30, 2014.

Completing the ub04 claim form guidelines for facility. Committees official ub04 data specifications manual. Because it serves many payers, a particular payer may not need some data elements. These instructions are to be supplemented with the information and codes in the uniform billing manual for the ub 04. This form, also known as the ub 04, is a uniform institutional provider bill suitable for use in billing 25. If more than one value point of origin for admission or visit codes cms.

Sample ub 04 form for inpatient and outpatient services follows as well as a breakdown of each field description and what is. Code code field number or value 81a381d3 163 condition codes 1828 77. New ub 04 cms 1450 claim instructions for personal care services wisconsin medicaid will begin accepting the new ub 04 cms 1450 claim form for ub claims received on and after march 1, 2007. Ub 04 desk reference feb 21, 2014 these values are valid for paper claim submission on the ub 04 claim form only. Ub04 claim form instructions geisinger health plan. Wisconsin medicaid will continue to accept the ub 92. The ub 04 data specifications manual contains a blank facsimile of. Effective october 1, 2014, ahcccs determines medicaid reimbursement.

Oregon medical fee and payment rules oregon administrative. Health first colorado ub04 impatientoutpatient hospital. The ub04 claim form is used exclusively for institutional billing and includes several fields that accommodate the use of. This update also aligns how we process print ub 04 claims with the way we have been processing similar electronic claim submissions in regard to the type of admissionvisit field. January 2014 update of the hospital outpatient prospective payment system opps. 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.

The chars companion guide and procedure manual supplement the asc x12 standards for. Completion of cms1450 ub04 claim form to part a claims center. This form, also known as the ub04, is a uniform institutional provider bill suitable for. Ub 04 presentation cahaba gba feb 28, 2014 january 14, 2014.

Anthem to the ub 04 data specifications manual 2014 and cms manual transmittal 1104 are. Condition codes using the twodigit codes from the nubc manual for up to 11 occurrences. Refer to the colorado medical assistance program ub04 revenue code table appendix q. Use bill type codes 21x or 28x for nursing facility and nursing facility hospice. Official ub 04 data specifications manual, 2014, is ed by american hospital association aha, chicago, illinois. Ub04 claim form instructions form locator name instructions 1. Ub 04 claim form completion instructions for private duty nursing and private duty nursing for ventilatordependent members. Pennsylvania uniform claims and billing form reporting manual inpatient ub 04 data reporting pennsylvania health care cost containment council april 2007 revised. Federally qualified health centers fqhcs and rural. Jul 17, 2007 procedure coding system hcpcs codes to bill medicaid for drugs dispensed national uniform billing committee nubc designated the in the ub04, there are a number of value codes to indicate various a3 national uniform billing committee occurrence span codes not used for medicare. Sep 16, 2016 ub 04 claim form instructions enter the hour using a twodigit code below that in the amount box, enter the number, amount, or 59. Patient address, city, state, zip code, and county code.

For inpatient service only inpatient charges for newly covered services not paid by the hmo. The instructions describe what information must be entered in each of the block numbers of the ub04 cms1450 paper claim form. This section provides procedures and guidelines for claim submission and timeliness except for local educational agency lea providers. Commonwealth of kentucky ky medicaid provider billing. Code structure 2nd digittype of facility cms will process this as the 1st digit 3rd digitbill classification except clinics and special. How the ub 04 form is used to bill insurance companies by.

No portion of official ub04 manual may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic. Audiology billing manual or the laboratory billing manual under cms 1500 for more information. The purpose of this change request cr is to publish an update to iom, medicare claims processing manual, pub. Enter the 2 digit code that best describes the members status for this billing period. In the field column of the table below, some field numbers are preceded with an asterisk. Official ub04 data specifications manual, 2014, is ed by american hospital association aha, chicago, illinois. 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. Unless otherwise noted, all data form locators on the ub 04 have the same attributes specifications for the health first colorado as those indicated in the nubcub 04 reference manual. Inpatient claims ub04 pennsylvania health care cost. Value codes and amounts field locator 3941 on the ub04 claim. Chapter 25 completing and processing the form cms1450 data set.

This form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing 25. Ub 04 desk reference for long term care facilities. Special instructions for labor and delivery claims. This section illustrates billing examples of medicare medical crossover claims for part b services billed to part a contractors submitted hard copy on a ub 04 claim form and correlating remittance advice ra examples. All institutional claims submitted on behalf of medicare patients must be in the cms1450 ub 04 claim format.

Jun 1, 2014 of mailing of the final order of allowance of the claim or the condition being treated. Required required for additional information on the completion of fields, please refer to the nubc official ub 04 data specifications manual. This section contains medicare requirements for use of codes maintained by the nubc that are. Official ub04 data specifications manual 2015 national uniform of the ub04 manual, the american hospital association granted to you a 04 manual andor codes and descriptions. If any information is missing or entered incorrectly, the dde system will display reason codes on the. Completion of cms1450 ub04 claim form to part a claims. February 21, 2014 06 medicare blood deductible paper claims only. Macs may include a crosswalk between the asc x12n 837i and the. Wisconsin medicaid will begin accepting the new ub 04 cms 1450 claim form for ub. For a current list of patient status codes, please refer to the nubc ub 04 manual. New ub04 cms 1450 claim instructions for personal care. Delivery is a benefit for recipients of emergency medicaid, but. Health first colorado ub04 inpatientoutpatient billing manual.

Although the instructions that follow are based on the ub04 paper claim form, they are also intended as a guideline for electronic billers to find out what information they need to provide in their claims. This manual is designed to assist facilities with their phc4 inpatient data submission. A service line date is required on all hospice services. For more information on revenue codes, refer to the national uniform billing. Point of origin codes update to the ub 04 cms1450 manual code list national uniform billing committee nubc, will be accepted into the fiscal. For more information on value codes and amounts, refer to the national uniform billing committees official ub 04 data specifications manual at. The official ub 04 data specifications manual, ed by the american hospital association, is the only official source of ub 04 billing information adopted by the national uniform billing committee nubc. Form locators 1828 condition codes required, if applicable enter the codes identifying a condition related to this claim, if appropriate. Medicare claims processing manual, chapter 22 centers for 60. Request for temporary total compensation c84 to document 70 on ub 04. Blue cross newsletter april 25, 2014 value code required. Specific codes required refer to ub 04 manual ra 14 priority type of visit enter the 1digit code indicating the priority of this admissionvisit.

Pay to address pay to address if different than field 1. Cms1450, also known as the ub04, is the standard claim form to manual contains the updated specifications for the data elements and codes of the medicare claims processing manual is entitled fee schedule condition codes. Refer to the ub04 billing manual for more information. Procedure manual for submitting discharge data ub04 and 837i 5010. Instructions for completing the ub04 claim form san francisco. For specific claim completion instructions, refer to the ub 04.

The ub 04 claim form is incorporated by reference in 59g4. See the ub04 manual for revenue codes and abbreviations. Shield of texas offers this guide to help you complete the ub 04 form for your patients with blue cross facility coverage. For a list of condition codes, occurrence codes, occurrence span codes, value codes, revenue codes and all other required data reported on the ub 04, please visit the nubc website for the official ub 04 data specifications manual. The value codes to be submitted when billing private room revenue codes according to the ub 04 data specifications manual 2014 and cms manual transmittal 1104 are. Value codes and amounts enter the appropriate twodigit value code and value if there is a value code and value appropriate for this claim. Billing committees official ub04 data specifications manual at.

Detail record quick reference includes ub04 form locator. New and revised place of service codes pos for outpatient. The following instructions explain how to complete the ub04 claim form and whether a field is required, required if applicable, or not required. Ub 04 claim forms may be ordered from the medicaid fiscal agent by. A complete list of hcpcs codes that require the ndc identifiers and where to submit codes on the cms1500 and ub04 forms can be found at the medical drug management section of provider to expedite claim processing, please be sure you have the covered persons current id card number at each office visit. 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. All medicare coinsurance days march 2014 anthem mar 23, 2014 to align with the implementation of the cms, ub04 and unbc industry standards manual 2014 and cms manual transmittal 1104 are. All code values listed in the nubc ub 04 reference manual for each form locator. Apr 28, 2016 revised and clarified place of service pos coding instructions. Field requirement field name and instructions for ub 04 form. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. Audiology billing manual or the laboratory billing manual. Use the following claim form completion instructions, not the form locator descriptions printed on the claim form, to avoid claim denial or inaccurate claim payment.

Dec 24, 2018 instructions for completing the ub 04 form fields marked with an asterisk. For a current list of patient status codes, please refer to the nubc ub04 manual. This fourdigit alphanumeric code gives three specific pieces of information. In these fields, use hipaacompliant codes that are current for the dates of service on the claim. Fields marked required in the ub04 claim form instructions are.

Blue cross newsletter april 25, 2014 value code required for. The type of bills codes are described in chapter 1. Crosswalk adjustment reason codes and remittance advice ra. September 29, 2014 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 claim found in. Form cms1450 ub 04 this form, also known as the ub 04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. Pos code 22 will be used on the physicians claim for the pc to indicate r3315cp cms. The ub04 claim form and npi the ub04 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. 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 claim form completion instructions for private duty. The national uniform billing committee nubc maintains lists of approved coding for the form. Ub 04 claim form completion for promise icfmr, icforcs and state mr centers. No portion of official ub 04 manual may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic.

Examples in this section are to assist providers in billing home health agency hha services on the ub 04 claim form. This manual contains the updated specifications for the data elements and codes included on the cms1450 and used in the 837i transaction standard. The national uniform billing committee nubc makes their ub 04 manual available through their website. Transmitting data when claim entry is completed, press f9 to store the claim and transmit the data. This code reflects the elimination of all previously paid claims in their. For further electronic claim submission information, refer to the emedny 5010 companion guide which is available at. Patient control number enter your facilitys unique account number. The instructions included in this section are excerpts from medicare instructions rev. Ub 92 to ub 04 crosswalk 261 ub 04 mapping to 837 claim transaction 005010 268 ub 04 837 reporting differences 283 change log 284 ub 04 form front 285 back of ub 04 form for informational purposes only 286 ub 04 cms1450 printing specifications 287 page 4 of 289 national uniform billing committee official ub 04 data specifications manual 2019. Ub04 change implementation calendar effective date form locator. 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. Complete all form locators unless otherwise indicated. Sample ub04 form for inpatient and outpatient services follows as well as a breakdown of each field description and what is required. 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.

Effective april, 2014, contracting facilities with only private rooms are. The following instructions explain how to complete the ub 04 claim form and whether a field is required, required if applicable, or not required. Ub04 user guide blue cross blue shield of new mexico. For general policy information, refer to the home health agencies hha section in this manual. Patients relationship to insured enter the code for the patients. 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.

Official ub04 data specifications manual and the icd9cm official. The ub 04 xref field will direct you to the field that correlates to the ub 04 form noted in the manual. Ub04 condition codes icd 10 codes, cpt codes, hcpcs codes. In the amount box, enter the number, amount, or ucr value associated with that code. Health first colorado ub04 inpatientoutpatient billing. Sep 18, 2014 the most current specifications for the data elements and codes included on the ub 04 claim form and the electronic hipaa institutional 837 health care claim transaction standard is available via the national uniform billing committees official ub 04 data specifications manual on the nubc website. If you received a letter indicating that you were randomly selected to origin for admission or visit codes to the ub04 cms1450 manual code list. This form, also known as the ub 04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. 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. The following updates will affect medicare advantage. The cms claims processing manual, pub 100 04, chapter 25 contains general instructions for completing the cms1450 for billing. Description fl01 billing provider name fl01 billing provider street address.

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. For public health datareporting only when required by state or federal law or regulations. For complete information regarding ub 04 coding please refer to the cms iom publication 100 04. No other publication governmental or privatecommercial can be considered authoritative. Provider handbook 837 institutional ub 04 claim form. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual. Fl18 condition code fl19 condition code fl20 condition code fl21 condition code fl22 condition code. Refer to national uniform billing committee nubc information for expanded definitions of codes. This manual, ed by the american hospital association, is the only official source of ub data. This document explains the ub04 claim form, which is used for submitting claims for reimbursement for specially designated facilities. Home health agencies hha billing examples home hlth ex. These instructions can be used in combination with the cms1450 ub04 claim form. Macs may include a crosswalk between the asc x12n 837i and the cms1450 on their websites.