No portion of official ub 04 manual may be reproduced, sorted in a retrieval system, or transmitted, in. Icn 006926 june 2018 additional information is available to subscribers of the nubc official ub04 data specifications manual. Medicare billing form cms1450 and the 837 institutional. On a noncolor printout, required fields will appear darkest. Maintenance organization hmo contracted by the texas health and human services. Blue cross and blue shield of texas offers this guide to help you complete the ub04 form for your patients with blue cross facility coverage. Ub04 claim forms may be ordered from the medicaid fiscal agent by. And the claim contains programapproved cpt, icd9, revenue and place of service. Fqhc or rhc that submits a ub04 or 837 institutional 837i electronic transaction must have at least one 1 claim line that identifies revenue code 0529 for fqhcs or revenue code 0521 for rhcs. This comprehensive listing of fee maximums is used to reimburse a physician andor other providers on a feeforservice basis. Local coverage determination for allergy testing l36241. Completing the ub04 claim form overview introduction this chapter describes how to complete and submit the ub04 claim form for payment from the florida medicaid program through the medicaid fiscal agent.
Fact end stage renal disease esrd sheet and dialysis. Obtain claim forms by calling the american medical association at. The texas medicaid provider procedures manual is the providers principal source of information about texas medicaid. Firstcare prepared this manual, which is an extension of the contract, for use by firstcare. Ub04 desk reference for hospitals patients relationship to insured codes.
December 2016 texas medicaid provider procedures manual. This manual, ed by the american hospital association, is the only official source of ub data. Ub04 form the uniform bill ub04 is the standardized billing form for institutional services. Effective for claims received on and after may 1, 2014, forwardhealth will deny claims for. To license the electronic data file of ub 04 data specifications, contact tim carlson at 312 8936816 or laryssa marshall at 312 8936814. Overview, continued ordering claim forms electronic claims filing is preferred but if you must file a paper claim, you will need to use the standard ub 04 or cms 1500 0805 claim form. If the nonhospital provider is required to submit a procedure code for reimbursement, the provider. Chapter 25 completing and processing the form cms 1450 data set. Medical requires that hospices document all coexisting or additional diagnoses related to the recipients terminal illness on hospice claims. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual. Federally qualified health centers fqhcs and rural.
How to complete a ubo4 form completely and correctly line. Subchapter t submission of clean claims texas department of. 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. Legibility and completion standards section of this manual. All required fields are completed on an original cms 1500 claim form, cms 1450 ub04 claim form, edi electronic claim format, or claims submitted on our secure provider portal, individually or batch. 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. 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. For information on the ub04 billing form, or to obtain an official ub04 data specifications. Home health agencies hha billing examples home hlth ex.
Claims must be submitted on a standard hcfa 1500 form or ub92ub04 to the address designated. Local coverage determination for biomarkers overview l35062. Committees official ub04 data specifications manual. 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. Updates to this manual will be posted on our website at. Outpatient services section of this manual for instructions to complete claim fields not explained in the following example. 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. March 1, 2007 ed by the american hospital association aha. Information on how to complete each of these forms is available later in this manual. Detail record quick reference includes ub04 form locator. Ub04 institutional providers data element requirements for nonelectronic clean claims. This oklahoma inpatient discharge data reporting manual, issued in september 2014, supersedes and replaces all previous versions. Medical billing training do ascs use cms 1500 or ub 04 forms duration.
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, recording or otherwise, without prior. Jul 27, 2014 the main difference between the ub 04 form and the cms 1500 form is the cms 1500 is basically has less stuff on it, like less spaces for stuff, because when we go to the doctor and you have an. Completing the ub04 claim form guidelines for facility. As of october 7, 20, the national uniform billing committee discontinued type of bill code 33x and replaced it with type of bill codes 32x and 34x for home health claims. Ub04 claim form, in a format required by the health insurance portability and accountability. Overview of the ub04 billing claim form verywell health. Health first colorado ub04 federally qualified health. The xml format described in this manual will be the required format for data submissions for calendar year 2015 and forward. Shield of texas offers this guide to help you complete the ub04 form for your patients with blue cross facility coverage.
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. Ensure that each claim is on the correct form, ub 04 or cms1500, and that each claim includes correct entries. All other lines on the claim should have the revenue code most appropriate for the service. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. Committee nubc official ub 04 data specifications manual 2008 version 2. To ensure our provider community has access to the most current fee schedules used by part b providers, select the appropriate.
To license the electronic data file of ub04 data specifications, contact tim carlson at 312 8936816 or laryssa marshall at 312 8936814. All required fields are completed on an original cms 1500 claim form, cms 1450 ub 04 claim form, edi electronic claim format, or claims submitted on our secure provider portal, individually or batch. Unless otherwise noted, all data form locators on the ub04 have the same attributes specifications for the health first colorado as those indicated in the nubcub04 reference manual. Form cms1450 ub04 this form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. Transmittal 2874, dated february 6, 2014, is being rescinded and replaced by transmittal 2922. How to complete a ubo4 form completely and correctly line by. Nov 19, 2010 medical billing training do ascs use cms 1500 or ub 04 forms duration. 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. Ssimedicaid reimbursement manual texas health and human. An explanation of how to bill using the fromthrough method is included in the ub04 special billing instructions for outpatient services section of this manual. Inside is a blank ub04 claim form for reference, and information on medica s. Instruction manual texas bcu43 instruction manual 45 pages. Uniform claims and billing form reporting manual december 2019 page 7 of 182 ambulatoryoutpatient ub04 data reporting data element description field number ub04 form locator page number payto address 2b 44 payto city, state, zip code 2c12c3 45 payto name 2a 43 point of origin for admission or visit 15 69.
No other publication governmental or privatecommercial can be considered authoritative. Claims initially received beyond the 6month time frame, except claims involving retroeligibility, will be denied. Information 404 6563875 amendment november 4, 2014 page 1 of 2. California division of workers compensation medical. Committee nubc official ub04 data specifications manual 2008 version 2. It specifies the billing, payment and coding rules for paper and electronic medical treatment bill submissions in the california workers compensation system. Although developed by the centers for medicare and medicaid cms, the form has become the standard form used by all insurance carriers. Uniform claims and billing form reporting manual december 2019 page 7 of 182 ambulatoryoutpatient ub 04 data reporting data element description field number ub 04 form locator page number payto address 2b 44 payto city, state, zip code 2c12c3 45 payto name 2a 43 point of origin for admission or visit 15 69.
Local coverage determination for cataract extraction. Official ub 04 data specifications manual, 2014, is ed by american hospital association aha, chicago, illinois. Ub04 instructions ub04 instructions page 5 of 11 revised 11. Texas 2020 ambetter provider manual ambetter from superior. Local coverage determination for neurophysiology evoked. Feeforservice provider billing manual submitted no later than 6 months from the date that eligibility is posted.
Fqhc or rhc that submits a ub 04 or 837 institutional 837i electronic transaction must have at least one 1 claim line that identifies revenue code 0529 for fqhcs or revenue code 0521 for rhcs. The instructions describe what information must be entered in each of the block numbers of the ub04 cms1450 paper claim form. Compensation deduction limit adjusted the limit on the compensation deduction has been adjusted, as required by tax code section 171. Appendix f, texas standard prior authorization form 155 appendix g, outpatient prior authorization form 156 appendix h, inpatient prior authorization form 157 appendix i, sample ub04 claim form 158 appendix j, sample cms 1500 claim form 159 appendix k, sample of claims appeal form 160 appendix l, disease management patient referral form 161. Emedny information assisted living program alp version 2011 01 612011 page 2 of 9. Instructions for completing the ub04 claim form are based on the current national uniform billing committee nubc ub04 reference manual. We have 1 texas bcu43 manual available for free pdf download. 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. Paper claims should only be submitted on original red ink on white paper claim forms.
Because it serves many payers, a particular payer may not need some data elements. For more information on type of bill, refer to the national uniform billing. 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. For additional claim preparation information, refer to the forms. Our provider manual and quick reference guide qrg are. January 2014 update of the hospital outpatient prospective payment system opps.
Updates are generally available the month following the effective date of the change. For hospital inpatient claims, date of service means the date of discharge of the patient. The hospital and the physician office or other entity are both owned by a third party, such as a health system. Federally qualified health centers fqhcs and rural health. The manual is regularly updated to reflect the most recent policy and procedure changes. All claim submissions will be subject to 5010 validation procedures based on cms industry standards. 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. 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. A fee schedule is a complete listing of fees used by medicare to pay doctors or other providerssuppliers.
Shield of texas offers this guide to help you complete the ub 04 form for your patients with blue cross facility coverage. A complete listing can be found in the provider manual and the evidence of coverage. The cms1450 ub 04 for institutional services refer to the cms1450 ub 04 claim form section these forms are available in both electronic and hard copypaper format. 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. Ssimedicaid reimbursement manual texas texas department hospital, the place of service must indicate inpatient or outpatient status at the time of service. The ub04 claim form is incorporated by reference in 59g4.