UB-04 Claim Form Instructions

UB-04 Claim Form Instructions
Required (R) fields must be completed on all claims. Conditional (C) fields must
be completed if the information applies to the situation or the service provided.
NOTE: Claims with missing or invalid Required (R) field information will be
rejected or denied.
Field #
Field Description
1
(UNLABELED FIELD)
2
(UNLABELED FIELD)
3a
PATIENT CONTROL NO.
3b
MEDICAL RECORD
NUMBER
4
TYPE OF BILL
5
FED. TAX NO.
6
STATEMENT COVERS
PERIOD
FROM/THROUGH
Instructions and Comments
Line 1: Enter the complete provider name.
Line 2: Enter the complete mailing address.
Line 3: Enter the City, State, and zip+4 code (include
hyphen)
Line 4: Enter the area code and phone number.
Enter the Pay-To Name and Address.
Enter the facility patient account/control number
Enter the facility patient medical or health record number.
Enter the appropriate 3-digit type of bill (TOB) code as
specified by the NUBC UB-04 Uniform Billing Manual
minus the leading “0” (zero). A leading “0” is not
needed. Digits should be reflected as follows:
¾ 1st digit - Indicating the type of facility.
¾ 2nd digit - Indicating the type of care
¾ 3rd digit - Indicating the billing sequence.
Enter the 9-digit number assigned by the federal
government for tax reporting purposes.
Enter begin and end or admission and discharge dates for
the services billed. Inpatient and outpatient observation
stays must be billed using the admission date and
discharge date. Outpatient therapy, chemotherapy,
laboratory, pathology, radiology and dialysis may be billed
using a date span. All other outpatient services must be
billed using the actual date of service. (MMDDYY)
Required or
Conditional*
R
Not Required
Not Required
R
R
R
R
7
(UNLABELED FIELD)
Not Used
8a – Enter the patient’s 10-digit Medicaid identification
number on the member’s CENPATICO BEHAVIORAL
HEALTH I.D. card.
8
a-b
Not Required
Not Required
8b – Enter the patient’s last name, first name, and middle
initial as it appears on the CENPATICO BEHAVIORAL
HEALTH ID card. Use a comma or space to separate the
last and first names.
PATIENT NAME
¾
9
a-e
PATIENT ADDRESS
10
11
BIRTHDATE
SEX
12
ADMISSION DATE
13
ADMISSION HOUR
14
ADMISSION TYPE
15
ADMISSION SOURCE
Titles (Mr., Mrs., etc.) should not be reported in this
field.
¾ Prefix: No space should be left after the prefix of a
name e.g. McKendrick. H
¾ Hyphenated names: Both names should be
capitalized and separated by a hyphen (no space).
¾ Suffix: A space should separate a last name and
suffix.
Enter the patient’s complete mailing address of the
patient.
Line a: Street address
Line b: City
Line c: State
Line d: ZIP code
Line e: Country Code (NOT REQUIRED)
Enter the patient’s date of birth (MMDDYYYY)
Enter the patient's sex. Only M or F is accepted.
Enter the date of admission for inpatient claims and date
of service for outpatient claims.
Enter the time using 2-digit military time (00-23) for the
time of inpatient admission or time of treatment for
outpatient services.
00-12:00 midnight to 12:59 12- 12:00 noon to 12:59
01- 01:00 to 01:59
13- 01:00 to 01:59
02- 02:00 to 02:59
14- 02:00 to 02:59
03- 03:00 to 03:39
15- 03:00 to 03:59
04- 04:00 to 04:59
16- 04:00 to 04:59
05- 05:00 to 05:59
17- 05:00 to 05:59
06- 06:00 to 06:59
18- 06:00 to 06:59
07- 07:00 to 07:59
19- 07:00 to 07:59
08- 08:00 to 08:59
20- 08:00 to 08:59
09- 09:00 to 09:59
21- 09:00 to 09:59
10- 10:00 to 10:59
22- 10:00 to 10:59
11- 11:00 to 11:59
23- 11:00 to 11:59
Required for inpatient admissions (TOB 11X, 118X, 21X,
41X). Enter the 1-digit code indicating the priority of the
admission using one of the following codes:
1 Emergency
2 Urgent
3 Elective
4 Newborn
Enter the 1-digit code indicating the source of the
admission or outpatient service using one of the following
R
R
(except line 9e)
R
R
R
R
C
R
codes:
1 Physician Referral
2 Clinic Referral
4 Transfer from a hospital
6 Transfer from another health care facility
7 Emergency Room
8 Court/Law enforcement
9 Information not available
Enter the time using 2-digit military time (00-23) for the
time of inpatient or outpatient discharge.
16
17
DISCHARGE HOUR
PATIENT STATUS
00-12:00 midnight to 12:59
12- 12:00 noon to 12:59
01- 01:00 to 01:59
13- 01:00 to 01:59
02- 02:00 to 02:59
14- 02:00 to 02:59
03- 03:00 to 03:39
15- 03:00 to 03:59
04- 04:00 to 04:59
16- 04:00 to 04:59
05- 05:00 to 05:59
17- 05:00 to 05:59
06- 06:00 to 06:59
18- 06:00 to 06:59
07- 07:00 to 07:59
19- 07:00 to 07:59
08- 08:00 to 08:59
20- 08:00 to 08:59
09- 09:00 to 09:59
21- 09:00 to 09:59
10- 10:00 to 10:59
22- 10:00 to 10:59
11- 11:00 to 11:59
23- 11:00 to 11:59
REQUIRED for inpatient claims. Enter the 2-digit
disposition of the patient as of the “through” date for the
billing period listed in field 6 using one of the following
codes:
STATU Description
S
01
Discharged to home or self care
02
Transferred to another short-term general
hospital
03
Transferred to a SNF
04
Transferred to an ICF
05
Transferred to another type of institution
06
Discharged home to care of home health
07
Left against medical advice
08
Discharged home under the care of a Home
IV provider
20
Expired
30
Still patient or expected to return for
outpatient services
31
Still patient – SNF administrative days
32
Still patient – ICF administrative days
62
Discharged/Transferred to an IRF, distinct
rehabilitation unit of a hospital
65
Discharged/Transferred to a psychiatric
hospital or distinct psychiatric unit of a
hospital
Not Required
C
REQUIRED when applicable. Condition codes are used to
identify conditions relating to the bill that may affect payer
processing.
18-28
CONDITION CODES
Each field (18-24) allows entry of a 2-character code.
Codes should be entered in alphanumeric sequence
(numbered codes precede alphanumeric codes).
C
For a list of codes and additional instructions refer to the
NUBC UB-04 Uniform Billing Manual.
29
ACCIDENT STATE
30
(UNLABELED FIELD)
Not Required
Not Used
Not Required
Occurrence Code: REQUIRED when applicable.
Occurrence codes are used to identify events relating to
the bill that may affect payer processing.
31-34
a-b
OCCURRENCE CODE
and
OCCURENCE DATE
Each field (31-34a) allows entry of a 2-character code.
Codes should be entered in alphanumeric sequence
(numbered codes precede alphanumeric codes).
C
For a list of codes and additional instructions refer to the
NUBC UB-04 Uniform Billing Manual.
Occurrence Date: REQUIRED when applicable or when
a corresponding Occurrence Code is present on the same
line (31a-34a). Enter the date for the associated
occurrence code in MMDDYYYY format.
Occurrence Span Code: REQUIRED when applicable.
Occurrence codes are used to identify events relating to
the bill that may affect payer processing.
35-36
a-b
OCCURRENCE SPAN
CODE
and
OCCURRENCE DATE
Each field (31-34a) allows entry of a 2-character code.
Codes should be entered in alphanumeric sequence
(numbered codes precede alphanumeric codes).
For a list of codes and additional instructions refer to the
NUBC UB-04 Uniform Billing Manual.
C
37
(UNLABELED FIELD)
38
RESPONSIBLE PARTY
NAME AND ADDRESS
Occurrence Span Date: REQUIRED when applicable or
when a corresponding Occurrence Span code is present
on the same line (35a-36a). Enter the date for the
associated occurrence code in MMDDYYYY format.
REQUIRED for re-submissions or adjustments. Enter the
12-character DCN (Document Control Number) of the
original claim. A resubmitted claim MUST be marked
using large bold print within the body of the claim form
with “RESUBMISSION” to avoid denials for duplicate
submission. NOTE: Re-submissions may NOT currently
be submitted via EDI.
C
Not Required
Code: REQUIRED when applicable. Value codes are
used to identify events relating to the bill that may affect
payer processing.
Each field (39-41) allows entry of a 2-character code.
Codes should be entered in alphanumeric sequence
(numbered codes precede alphanumeric codes).
39-41
a-d
VALUE CODES
CODES and AMOUNTS
Up to 12 codes can be entered. All “a” fields must be
completed before using “b” fields, all “b” fields before
using “c” fields, and all “c” fields before using “d” fields.
C
For a list of codes and additional instructions refer to the
NUBC UB-04 Uniform Billing Manual.
Amount: REQUIRED when applicable or when a Value
Code is entered. Enter the dollar amount for the
associated value code. Dollar amounts to the left of the
vertical line should be right justified. Up to 8 characters
are allowed (i.e. 199,999.99). Do not enter a dollar sign
($) or a decimal. A decimal is implied. If the dollar amount
is a whole number (i.e. 10.00), enter 00 in the area to the
right of the vertical line.
General
Information
Service Line Detail
Fields
42-47
The following UB-04 fields – 42-47:
¾ Have a total of 22 service lines for claim detail information.
¾ Fields 42, 43, 45, 47, 48 include separate instructions for the
completion of lines 1-22 and line 23.
42
Line 1-22
REV CD
Enter the appropriate 4 digit revenue codes itemizing
accommodations, services, and items furnished to the
patient. Refer to the NUBC UB-04 Uniform Billing Manual
for a complete listing of revenue codes and instructions.
R
Enter accommodation revenue codes first followed by
ancillary revenue codes. Enter codes in ascending
numerical value.
42
Line 23
43
Line 1-22
43
Line 23
44
Rev CD
DESCRIPTION
PAGE ___ OF ___
HCPCS/RATES
Enter 0001 for total charges.
Enter a brief description that corresponds to the revenue
code entered in the service line of field 42.
Enter the number of pages. Indicate the page sequence
in the “PAGE” field and the total number of pages in the
“OF” field. If only one claim form is submitted enter a “1”
in both fields (i.e. PAGE “1” OF “1”).
REQUIRED for outpatient claims when an appropriate
CPT/HCPCS code exists for the service line revenue code
billed. The field allows up to 9 characters. Only one
CPT/HCPC and up to two modifiers are accepted. When
entering a CPT/HCPCS with a modifier(s) do not use a
spaces, commas, dashes or the like between the
CPT/HCPC and modifier(s)
Refer to the NUBC UB-04 Uniform Billing Manual for a
complete listing of revenue codes and instructions.
R
R
R
C
The following revenue codes/revenue code ranges must
always have an accompanying CPT/HCPC.
45
Line 1-22
45
Line 23
46
47
Line 1-22
47
Line 23
48
Line 1-22
48
Line 23
49
300-302
329-330
360-361
610-612
304-307
333
363-366
615-616
309-312
340-342
368-369
618-619
314
349-352
400-404
634-636
319-324
359
490-499
923
REQUIRED on all outpatient claims. Enter the date of
service for each service line billed. (MMDDYY)
Enter the date the bill was created or prepared for
submission on all pages submitted. (MMDDYY)
Enter the number of units, days, or visits for the service. A
value of at least “1” must be entered.
C
TOTAL CHARGES
Enter the total charge for each service line.
R
TOTALS
Enter the total charges for all service lines.
R
NON-COVERED
CHARGES
Enter the non-covered charges included in field 47 for the
revenue code listed in field 42 of the service line. Do not
list negative amounts.
C
TOTALS
Enter the total non-covered charges for all service lines.
C
(UNLABELED FIELD)
Not Used
SERVICE DATE
CREATION DATE
SERVICE UNITS
R
R
Not Required
50
A-C
PAYER
51
A-C
HEALTH PLAN
IDENTIFICATION
NUMBER
REL. INFO
53
ASG. BEN.
54
PRIOR PAYMENTS
55
EST. AMOUNT DUE
56
NATIONAL PROVIDER
IDENTIFIER or
PROVIDER ID
57
OTHER PROVIDER ID
58
INSURED'S NAME
59
PATIENT
RELATIONSHIP
61
R
Not Required
REQUIRED for each line (A, B, C) completed in field 50.
Release of Information Certification Indicator. Enter “Y”
(yes) or “N” (no).
52
A-C
60
Enter the name for each Payer reimbursement is being
sought in the order of the Payer liability. Line A refers to
the primary payer; B, secondary; and C, tertiary.
R
Providers are expected to have necessary release
information on file. It is expected that all released invoices
contain "Y”.
Enter “Y" (yes) or "N" (no) to indicate a signed form is on
file authorizing payment by the payer directly to the
provider for services.
Enter the amount received from the primary payer on the
appropriate line when Medicaid/ CENPATICO
BEHAVIORAL HEALTH is listed as secondary or tertiary.
R
C
Not Required
Required: Enter provider’s 10-character NPI ID.
Enter the qualifier “1D” followed by your 6-digit Medicaid
Provider ID number.
For each line (A, B, C) completed in field 50, enter the
name of the person who carries the insurance for the
patient. In most cases this will be the patient’s name.
Enter the name as last name, first name, middle initial.
REQUIRED: Enter the patient's Insurance/Medicaid ID
exactly as it appears on the patient's ID card. Enter the
INSURED’S UNIQUE ID
Insurance /Medicaid ID in the order of liability listed in field
50.
GROUP NAME
R
Not Required
R
Not Required
R
Not Required
62
63
64
INSURANCE GROUP
NO.
TREATMENT
AUTHORIZATION
CODES
Not Required
Not Required
Enter the 12-character Document Control Number (DCN)
of the paid CENPATICO BEHAVIORAL HEALTH claim
when submitting a replacement or void on the
corresponding A, B, C line reflecting CENPATICO
DOCUMENT CONTROL
BEHAVIORAL HEALTH from field 50.
NUMBER
C
Applies to claim submitted with a Type of Bill (field 4)
Frequency of “7” (Replacement of Prior Claim) or Type of
Bill Frequency of “8” (Void/Cancel of Prior Claim).
65
EMPLOYER NAME
Not Required
66
DX
Not Required
Enter the principal/primary diagnosis or condition (the
condition established after study that is chiefly responsible
for causing the visit) using the appropriate release/update
of ICD-9-CM Volume 1& 3 for the date of service.
67
67
A-Q
PRINCIPAL DIAGNOSIS
Diagnosis codes submitted must be a valid ICD-9 codes
CODE
for the date of service and carried out to its highest digit –
4th or“5”. "E" and most “V” codes are NOT acceptable as a
primary diagnosis.
NOTE: Claims missing or with invalid diagnosis codes will
be denied for payment.
Enter additional diagnosis or conditions that coexist at the
time of admission or that develop subsequent to the
admission and have an effect on the treatment or care
OTHER DIAGNOSIS
received using the appropriate release/update of ICD-9CODE
CM Volume 1& 3 for the date of service.
Diagnosis codes submitted must be a valid ICD-9 codes
R
C
for the date of service and carried out to its highest digit –
4th or“5”. "E" and most “V” codes are NOT acceptable as a
primary diagnosis.
NOTE: Claims with incomplete or invalid diagnosis codes
will be denied for payment.
68
(UNLABELED)
Not Used
Not Required
Enter the diagnosis or condition provided at the time of
admission as stated by the physician using the
appropriate release/update of ICD-9-CM Volume 1& 3 for
the date of service.
69
ADMITTING DIAGNOSIS Diagnosis codes submitted must be a valid ICD-9 codes
for the date of service and carried out to its highest digit –
CODE
4th or“5”. "E" codes and most “V” are NOT acceptable as a
primary diagnosis.
R
NOTE: Claims missing or with invalid diagnosis codes will
be denied for payment.
Enter the ICD-9-CM code that reflects the patient’s reason
for visit at the time of outpatient registration. 70a requires
entry, 70b-70c are conditional.
70
a,b,c
PATIENT REASON
CODE
Diagnosis codes submitted must be a valid ICD-9 codes
for the date of service and carried out to its highest digit –
4th or“5”. "E" codes and most “V” are NOT acceptable as a
primary diagnosis.
R
NOTE: Claims missing or with invalid diagnosis codes will
be denied for payment.
71
72
a,b,c
73
Not Required
PPS / DRG CODE
EXTERNAL CAUSE
CODE
(UNLABELED)
Not Required
Not Required
REQUIRED on inpatient claims when a procedure is
performed during the date span of the bill.
74
PRINCIPAL
PROCEDURE
CODE / DATE
CODE: Enter the ICD-9 procedure code that identifies the
principal/primary procedure performed. Do not enter the
decimal between the 2nd or 3rd digits of code. It is implied.
C
DATE: Enter the date the principal procedure was
performed (MMDDYY).
REQUIRED for EDI Submissions.
REQUIRED on inpatient claims when a procedure is
performed during the date span of the bill.
74
a-e
OTHER PROCEDURE
CODE DATE
CODE: Enter the ICD-9 procedure code(s) that identify
significant a procedure(s) performed other than the
principal/primary procedure. Up to 5 ICD-9 procedure
codes may be entered. Do not enter the decimal between
the 2nd or 3rd digits of code. It is implied.
C
DATE: Enter the date the principal procedure was
performed (MMDDYY).
75
Not Required
(UNLABELED)
Enter the NPI and Name of the physician in charge of the
patient care:
NPI: Enter the attending physician 10-character NPI ID.
Taxonomy Code: Enter valid taxonomy code
76
ATTENDING PHYSICIAN
QUAL: Enter one of the following qualifier and ID number
0B – State License #
1G – Provider UPIN
G2 – Provider Commercial #
ZZ – Taxonomy Code
R
LAST: Enter the attending physician’s last name
FIRST: Enter the attending physician’s first name.
REQUIRED when a surgical procedure is performed:
NPI: Enter the operating physician 10-character NPI ID.
Taxonomy Code: Enter valid taxonomy code
77
OPERATING
PHYSICIAN
QUAL: Enter one of the following qualifier and ID number
0B – State License #
1G – Provider UPIN
G2 – Provider Commercial #
ZZ – Taxonomy Code
C
LAST: Enter the operating physician’s last name
FIRST: Enter the operating physician’s first name.
Enter the Provider Type qualifier, NPI, and Name of the
physician in charge of the patient care:
(Blank Field): Enter one of the following Provider Type
Qualifiers:
DN – Referring Provider
ZZ – Other Operating MD
82 – Rendering Provider
78 & 79
OTHER PHYSICIAN
NPI: Enter the other physician 10-character NPI ID.
C
QUAL: Enter one of the following qualifier and ID number
0B – State License #
1G – Provider UPIN
G2 – Provider Commercial #
LAST: Enter the other physician’s last name.
FIRST: Enter the other physician’s first name.
80
REMARKS
81
CC
Not Required
A: Taxonomy of billing provider. Use ZZ qualifier
R