2014 ub 04 manual condition

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, mechanical, photocopying. The nubc official ub04 data specifications manual includes a number of questions and answers related to. Completing the ub04 claim form guidelines for facility. Inpatient claims ub04 pennsylvania health care cost. For public health datareporting only when required by state or federal law or regulations. Documentation is insufficient to determine if condition is present at time of. This form, also known as the ub 04, is a uniform institutional provider. Sample ub04 form for inpatient and outpatient services follows as well as a breakdown of each field description and what is required. Sample ub 04 form for inpatient and outpatient services follows as well as a breakdown of each field description and what is. This article may contain references or links to statutes, regulations, or other policy materials. This section provides procedures and guidelines for claim submission and timeliness except for local educational agency lea providers. Ub 04 form the uniform bill ub 04 is the standardized billing form for institutional services. The ub04 claim form is used to bill for all hospital inpatient, outpatient, and. In these fields, use hipaacompliant codes that are current for the dates of service on the claim.

Ub04 user guide blue cross blue shield of new mexico. Revenue code enter a four digit revenue code beside each. Billing rules, of the feeforservice provider billing manual and the appropriate. The ub04 claim form is used to submit claims for inpatient and outpatient services by institutional. Refer to the colorado medical assistance program ub04 revenue code table appendix q for a.

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. Point of origin for admission or visit codes update to the ub 04 cms1450 manual code list i. 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. Please note that this manual reflects the changes associated with the ub04 format. Official ub04 data specifications manual, 2014, is ed by american hospital association aha, chicago, illinois. Medica follows national and state uniform billing guidelines for the submission of ub 04 claim forms, although some fields required by medicare or other payers may not be necessary for medica claims. When occurrence codes 0104 and 24 are entered, the provider must. Condition code only applicable to a xx8 type of bill. Billing committees official ub04 data specifications manual at.

Ub04 claim form instructions geisinger health plan. Mar 9, 2010 changes for condition code 47 used to replace code b are also or visit codes update to the ub 04 cms1450 manual code list. 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. Inside is a blank ub 04 claim form for reference, and information on medicas requirements for successful completion of the ub 04 claim form. Form locators 1828 condition codes required, if applicable enter the codes identifying a condition related to this claim, if appropriate. 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. Blue cross newsletter april 25, 2014 value code required for. The ub04 claim form is used exclusively for institutional billing and includes several fields that accommodate. 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. Refer to the ub04 billing manual for more information. Enter the appropriate condition codes that apply to this bill.

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 fl 6 on the ub04. The document includes instructions applicable to all hmsa lines of business. Instructions, ub04 dialysis ohio department of medicaid. The ub 04 claim form is incorporated by reference in 59g4. Request for temporary total compensation c84 to document 70 on ub 04. No other publication governmental or privatecommercial can be considered authoritative. Lcd and policy article summary for june 12, 2014 drafts released to final. The xml format described in this manual will be the required format for data submissions for calendar year 2015 and forward. 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. Because it serves many payers, a particular payer may not need some data elements.

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. The following changes apply to ub04 hospital billing for. This oklahoma inpatient discharge data reporting manual, issued in september 2014, supersedes and replaces all previous versions. 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. Effective october 1, 2014, ahcccs determines medicaid reimbursement for.

The chars companion guide and procedure manual supplement the asc x12 standards for. The ub04 claim form is used exclusively for institutional billing and includes several fields that. Comprehensive observation services and the 2midnight rule part 3 june 26, 2014 mary guyot principal. Iom language to chapter 25 for point of origin for admission or visit codes 7, b, c, and condition code 47. A guide for completing the ub 04 form the uniform bill ub 04 is the standardized billing form for institutional services. Jun 1, 2014 of mailing of the final order of allowance of the claim or the condition being treated.

Enter the appropriate twodigit condition code or codes if applicable to the. Refer to the ub04 manual as appropriate and follow. This cr also directs medicare systems changes for code 7. Patient discharge status \2 positions, numeric\\r\rrequired\r\rnote. Updates to the medicare claims processing internetonly manual iom. The ub04 claim form is used to submit claims for outpatient services by institutional facilities for. Ub 04 cms 1450 claim form instructions for personal care services. Effective april, 2014, contracting facilities with only private rooms are. Nov 18, 2014 under the shaded ub 04 field requirements section, corrected.

Condition, occurrence, value, and patient relationship, and remarks field codes. 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. Medical necessity of therapy services local coverage article. For further electronic claim submission information, refer to the emedny 5010 companion guide which is available at.

Detail record quick reference includes ub04 form locator. If providers do not use the emergency indicator correctly, the claim will deny with edit 104. Sep 18, 2014 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. Official ub 04 data specifications manual, 2014, is ed by american hospital association aha, chicago, illinois. Use when adding a modifier to a line that would make the charges covered on the adjustment that were noncovered on the previous claim.

For specific claim completion instructions, refer to the ub 04. Please note that providers may not submit claims on printouts of the interactive form. Forwardhealth update 201631 policy forwardhealth portal. Ub04 cms 1450 claim form instructions for inpatient. Please reference your ub 04 specifications manual for the data element name, a brief definition, refer to ub 04 manual for code and subcategory values. Refer to the ub 04 manual as appropriate and follow. In this section, you will find the codes we accept on the ub 04 claim form. Mar 4, 2014 ihcp regarding ub 04 updates and specific form locator definitions respectively. A ub04 with field descriptions and instructions is included in the link below. In the amount box, enter the number, amount, or ucr value associated with that code. Ub 04 claim form instructions the new claim form supports the use. 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. The uniform bill ub04 is the standardized billing form for institutional services. Ub04 cms 1450 claim form instructions for personal care.

Overview of the ub04 billing claim form verywell health. Ub04 change implementation calendar effective date form locator. Value codes and amounts field locator 3941 on the ub04 claim. Ub04 change implementation calendar effective date form. Hapter 6 billing on the ub04 claim form 3 22 arizona health care cost containment system feeforservice provider billing manual completing the ub04 claim form 1. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing. 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 ub04 claim form instructions eohhs ri. No portion of official ub04 manual may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying. For information on the ub 04 billing form, or to obtain an official ub 04 data specifications manual. Mar 6, 2008 the medicare uniform institutional provider bill ub04, form condition code 44inpatient admission changed to outpatient for use on it should use claim change reason code d1 only when the charges are the. These instructions are to be supplemented with the information and codes in the uniform billing manual for the ub04. 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.

This article includes tables of some of the most common condition, occurrence, value, patient relationship, and remarks field codes associated with msp claims. 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. The value codes to be submitted when billing private room revenue codes according to the ub04 data specifications manual 2014 and cms manual transmittal 1104 are. 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. If one of the above condition codes does not apply and there is a change to the covered charges this code should be used.

Ub 04 instructions ub 04 instructions page 1 of 11 revised 11. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual. Patients condition related to fields fields 10a 10c, whenever no fault. Provider data required enter the name, address, and phone number of the provider rendering the service. 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. Ub 04 claim forms may be ordered from the medicaid fiscal agent by. Ub 04 billing guide for promise icfmr, icforcs and state mr centers purpose of the document document format. A guide for completing the ub04 form blue cross blue. Blue cross and blue shield of oklahoma offers this guide to help you complete the ub 04 form for your patients with. 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. Refer to the ub 04 billing manual for more information. Instructions for completing the ub04 claim form san francisco. 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. Ub04 claim form instructions november 18, 2014 nevada medicaid.

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. Ub04 claim form instructions form locator name instructions 1. This form, also known as the ub04, is a uniform institutional provider bill. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. Form locators 18 28 condition codes enter x4, when one of the abovelisted. Local coverage determination for cataract surgery l344. The protecting access to medicare act of 2014 was signed into law. In the field column of the table below, some field numbers are preceded with an asterisk. Use when adding a modifier to a line that would make the charges covered on. Jul 29, 2016 recorded on the newborns claim using value code 54. Below is a link to hmsas interactive version of the ub 04 claim form.

Comprehensive observation services and the 2midnight rule. 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. Enter the four digit code that identifies the specific type status as of the through date. Manual developed by the national uniform billing committee nubc. Condition codes enter two digit alpha numeric codes up to eleven. Adobe reader or another pdf reader application is required to view the form. Ub 04 claim form instructions november 18, 2014 nevada medicaid. All codes used required when there is an occurrence code that applies to this claim. This manual, ed by the american hospital association, is the only official source of ub data.