Health first colorado ub04 hospice care billing manual. Instructions, ub04 dialysis ohio department of medicaid. 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. Odjfs instructions for completing the ub04 paper claim form manual developed by the national uniform billing committee nubc. The ihstribal billing manual, chapter 9 hospital and clinic services and. The ub04 data specifications manual is the official source of data specifications adopted by the nubc and contains codes. The ub04 cms 1450 paper claim form is limited to 28 items per inpatient and outpatient claim.
This guide gives detailed line by line instructions on how to complete the ub04 claim form. Covered days are reported in the value code field 39 41 as value code 80. Workers data from carriers via edi transmission of the cms 1500 claim forms and ub. Chapter 6 inpatient part a billing and snf consolidated billing pdf chapter 6 crosswalk pdf.
Ry2015 eohhs technical specifications manual for mass. Billing guidelines for health care provided to veterans and va. For electronic billing, please refer to the maryland medicaid 837i electronic companion guide, which can be found on our website. Providers can refer to the national uniform billing code website at. This form, also known as the ub04, is a uniform institutional provider bill suitable.
Below is a link to hmsas interactive version of the ub04 claim form. Sep 11, 2018 ry2019 eohhs technical specifications manual for masshealth acute hospital quality measures 12. This section illustrates billing examples of medicaremedi cal crossover claims for part b services billed to part a contractors submitted hard copy on a ub04 claim form and correlating remittance advice ra examples. The department of health care policy and financing the department periodically modifies billing information. Provider handbook 837 institutionalub04 claim form ub04 billing guide for promise inpatient hospitals provider handbook ub04 july 12, 2018 8 form locator number form locator name form locator code notes for a complete listing and description of condition codes, please refer to the ub04 desk reference, handbook. Therefore, the information in this manual is subject to change, and the manual is updated as new billing information is implemented. The measures that apply to ry2015 and ry2016 reporting are. For example, the recipients last name, first name and middle initial as indicated on the medicaid. This is an addendum to the national uniform billing committees ub04 data specifications manual, available at. Claim completion requirements, claim information and detailed examples will be discussed for the ub04. Point of origin for admission or visit codes centers for medicare this article is based on change request cr 6801 which updates the pointof.
Billing manuals south dakota department of social services. Please note that providers may not submit claims on printouts of the interactive form. The document includes instructions applicable to all hmsa lines of business. The 2016 michigan rbrvs fee schedule utilizes 2016 october release cms fee. All code values listed in the nubc ub04 reference manual for each form locator. Premera reference manual premera blue cross 023695 022012 ub04 billing chapter 12 page 1 12 ub04 billing. No other publication governmental or privatecommercial can be considered authoritative. Loop2400 sv205 if billing for more than one unit of service, enter the number of units on the same line where a revenue code other than revenue code 0001 was entered in form locator 42. Hospitals billing for services associated with low level emergency physician care 99281, 99282 should place a 1 in form locator 7 on the ub04.
You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. This form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. Completion of cms1450 ub04 claim form to part a claims. The national uniform billing committee nubc maintains lists of approved coding for the form. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual. Instructions and guideline for cms 1500 claim form and ub 04 form. Enter the fourdigit code from the national ub 04 manual for the provider type that indicates the type of bill using the following guidance by provider type. Please use the national ub 04 manual for specific codes. Medicare claims processing manual crosswalk centers for this form, also known as the ub04, is a uniform institutional provider bill suitable the provider enters the appropriate revenue codes from the following list to.
Chapter 25 completing and processing the form cms1450 data set. Nh medicaid final hospital provider billing manual new billing manual inquiries may be directed to the xerox provider relations unit. Enter the fourdigit code from the national ub04 manual for the provider type that indicates the type of bill using the following guidance by provider type. This chapter contains participation, claims and billing information for providers who bill on a. A copy of the ub04 billing manual can be obtained at. Please note that these instructions are specifically written to correlate with partners behavioral health managements claim management system alpha mcs. The claim may be denied or returned if a required field is incomplete. If atypical, enter the 7digit vermont medicaid id number in the shaded area. Enter the name and address of the facility 2 pay to nameaddressid situational. The ub04 is a claim form that is utilized for hospital services and select residential services. Although developed by the centers for medicare and medicaid cms, the form has become the standard form used by all insurance carriers.
When submitting the above claims, complete all items required by each payer who is to receive a copy of the form. All institutional claims submitted on behalf of medicare patients must be in the cms1450 ub04 claim format. Listed below is a series of manuals detailing the situational data elements and. Ensure that each claim is on the correct form, ub04 or cms1500, and that each claim includes correct entries. The ub04 is a uniform institutional bill suitable for use in billing multiple third party liability tpl payers. Hmsa has determined that it will use the national uniform billing committee nubc official ub04 data specifications manual as the standard source for codes and code descriptions to be entered in the various form locators fl. Billing provider s npi enter the billing provider s npi. Enter the billing provider s taxonomy code when applicable.
For information regarding the par program including policy and howto guides please visit the. Pay to address pay to address if different than field 1. Ub04 change implementation calendar as of 92519 page 3 of 3 the details of the following changes are contained in the ub04 manual or in the minutes. Billing provider enter the payee provider name and address individual provider format. The cms claims processing manual, pub 4, chapter 25 contains general instructions for completing the cms1450 for billing. Billing basics e december 2018 1 ub04 claim form introduction purpose the purpose of this module is to provide participants with detailed information about the completion of the ub04 claim form for medical services. Ub04 billing guide blue cross blue shield ma ub04appendix to nubc manual. However, in some cases, hmsa varies from nubc directions concerning whether a specific field is required or how the data is to be entered in a specific field. Ub04 special billing instructions for outpatient services. Pers ub04 billing guidelines version 2009 1 100109 page 3 of 47 section i purpose statement the purpose of this document is to assist the provider community in understanding and complying with the new york state medicaid nys medicaid requirements and expectations for. If the ub04 is submitted with an attending provider that is not appropriate as an attending provider the claim will be denied. Ub04 claim form instructions form locator name instructions 1. Effective with limited to, the nicu admission assessment and nicu flow sheet.
Ub 04 medicare discharge status code cms 1500 claim form. December 2016 texas medicaid provider procedures manual. Ub 04 medicare discharge status code,01 discharged to. Effective with outpatient date of service 112016, or inpatient discharge date 112016, ub04 claims must be billed with valid attending provider information or the claim will be denied. Many types of providers use the ub04 claim form to bill masshealth for services. If providers do not use the emergency indicator correctly, the claim will deny with edit 104. For determining the number of units, follow the guidelines below. Fields marked required in the ub04 claim form instructions are required on all paper claim submissions. Chapter 1 general billing requirements pdf chapter 1 crosswalk pdf chapter 2 admission and registration requirements pdf. Because it serves many payers, a particular payer may not need some data elements. Providers should refer to the code of colorado regulations, program rules 10 c. Kaiser permanente provider manual 2016 9 section 5. Health first colorado ub04 inpatientoutpatient billing.
Provider handbook 837 institutional ub04 claim form ub04 billing guide for promise inpatient hospitals provider handbook ub04 july 12, 2018 6 form locator number form locator name form locator code notes name is not available, you may enter baby boy or baby girl. Professional claims cms 1500 associated with the admission may need authorization separately depending on the service. Cms 1500 claim form and ub 04 form instruction and guide. The ub04 uniform billing form is the standard claim form that any institutional provider can use for the billing of medical and mental health claims. Adobe reader or another pdf reader application is required to view the form. Please use the national ub04 manual for specific codes.
Sep 12, 2014 to download a copy of the eohhs acute hospital rfa and contract. Ub04 change implementation calendar effective date form. Hospitals must use appropriate tob when billing for serious reportable events. Overview of the ub04 billing claim form verywell health. This authorization is for the institutional claim ub04. Enrollment instructions, updates, billing manuals, and companion guides are. Dec 7, 2015 6 a sample ub04 form is available on page 18 of cms pub 4 medicare 20 wcio workers compensation data specifications manual. For public health datareporting only when required by state or federal law or regulations. Medicare claims processing manual centers for medicare.