What is a UB 40 form?
An itemized medical bill lists in detail all the services that were provided during a visit or stay—such as a blood test or physical therapy—and may be sent to the patient directly. The UB-O4 form is used by institutions to bill Medicare or Medicaid and other insurance companies.
What goes in box 38 on a UB04?
Responsible Party Name and Address
38 Responsible Party Name and Address Required This field is for reporting the name and address of the person responsible for the bill. 39 – 41 Value Codes and Amounts Conditional These fields contain the codes and related dollar amounts to identify the monetary data for processing claims.
What are value codes on a UB04?
Value Codes
| Code | Description | Addtional Description |
|---|---|---|
| 81 | Non-Covered Days | Effective 03/01/07 Hardcopy UB04 Claims |
| 82 | Coinsurance Days | Effective 03/01/07 Hardcopy UB04 Claims |
| 83 | Lifetime Reserve Days | Effective 03/01/07 Hardcopy UB04 Claims |
| 84-99 | Reserved for National Assignment |
What is the difference between a CMS-1500 form and UB-04 form?
The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities. This would include things like surgery, radiology, laboratory, or other facility services. The HCFA-1500 form (CMS-1500) is used to submit charges covered under Medicare Part B.
What are the differences between the CMS 1500 and UB-04 claim form?
When a physician has a private practice but performs services at an institutional facility such as a hospital or outpatient facility, the CMS-1500 form would be used to bill for their services. The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities.
How many diagnosis codes can be reported on a UB04?
eighteen
(Note the UB-40 allows for up to eighteen (18) diagnosis codes.) The HCFA-1500 (CMS 1500): is a medical claim form used by individual doctors & practice, nurses, and professionals including therapists, chiropractors and outpatient clinics. It is not typically hospital-oriented.
What is Box 81 on a UB04?
Billing Tip: Enter code “81” when billing for emergency services, or the claim may be reduced or denied. An Emergency Certification Statement must be attached to the claim or entered in the Remarks field (Box 80).
What goes in box 51 on UB04?
Box 50a-c: (Required) Primary Payer Name (Secondary/Tertiary information can be entered on the lines below. Box 51a-c: (Not required) Health Plan ID should be entered into this box to identify the Health Plan Box 52a-c: (Not required) Each payer line will have a separate Assignment of Benefits Marker Box. Box 53a-c: ( …
What box is the discharge status on a UB?
Box 17
Box 17 – Patient Discharge Status: (Required if applicable) This field indicates the discharge status of the patient when service is ended/complete.
What is an A3 value code?
A3. Estimated Responsibility Payer A. Amount the provider estimates will be paid by the indicated payer. A4. Covered Self-Administrable Drugs – Emergency.
What is a UB-04 form?
The UB-04 is a claim form that is utilized for Hospital Services and select residential services. Please note that these instructions are specifically written to correlate with Partners Behavioral Health Management’s Claim Management System – Alpha MCS.
How many fields are there on a UB-04?
Fields of the UB-04 There are 81 fields or lines on a UB-04. They’re referred to as form locators or “FL.” Each form locator has a unique purpose:
How do I contact the UB-04 claim center?
If you have any questions regarding the UB-04 claim form, the NPI application process, or reporting your NPI to us, please call your Network Coordinator or Hospital/Ancillary Services Coordinator or contact Customer Service at 1-800-275-2583. UB-04 data field requirements
What are the NPI fields on a UB-04 form?
Include National Provider Identifier (NPI) information where indicated. More detailed instructions can be found at www.cms.gov or www.nubc.org . There are 81 fields or lines on a UB-04. They’re referred to as form locators or “FL.” Each form locator has a unique purpose: