UB-04 Claim Form

The UB-04 Claim Form, also known as CMS-1450, is used for submitting claims for reimbursement for specially designated facilities. The 837i is the electronic version of the form. Much like the 1500 Claim Form, maintained by the National Uniform Claim Committee, the UB-04 Claim Form is maintained by the National Uniform Billing Committee (NUBC) which maintains lists of approved codes used on various fields on the form (e.g., revenue codes, condition codes). Third-party payers, including Medicare, may have their own adaptations of the general instructions published by the NUBC.

What is a Facility?

The definition of a facility, also referred to as an institution, can vary by payer. Typically it includes places such as inpatient facilities like rehab facilities, psychiatric units, hospitals, surgical centers, and nursing facilities. Billing for these services is different than for professional services (e.g., physician) in that it often includes room charges as well as other supplies and equipment related to certain services (e.g., radiology supplies). 

Tip — Combined Claims:  Typically, the UB-04 Claim Form is only used for institutional claims. However, Critical Access Hospitals, Federally Qualified Health Centers, and Rural Health Clinics that bill Medicare are required to submit a “combined claim.” This is a claim that includes both facility and professional components (1500 Claim Form).

Instructions for Completing the UB-04 Claim Form

Although the NUBC publishes general guidelines, individual payers typically have adaptations which need to be followed. Refer to your organization’s contract or other published policies/guidelines for more information. The complete NUBC manual is only available with an NUBC subscription. 

It should be noted that Fields on the form are identified as FL along with a number. FL stands for “Form Locator” and is used to describe the different fields on the claim form. 

Medicare publishes their guidelines in the Medicare Claims Processing Manual, Chapter 25 - Completing and Processing the Form CMS-1450 Data Set. However, it should be noted that in many cases, the instructions simply state to use values as published by the NUBC. FindACode.com subscribers with a “Facility” subscription have access to the following:

• Type of Bill Facility Codes - FL 4
• Type of Bill Frequency Codes - FL 4
• Admission/Discharge Hour - FL 13/16
• Point of Origin Admission/Visit - FL 15
• Patient Discharge Status - FL 17
• Condition Codes - FLs 18-28
• Occurrence Codes - FLs 31-34
• Occurrence Span Codes - FLs 35-36
• Value Codes and Amounts - FLs 39-41
• Revenue Codes - FL 42
• Code Codes - FL 81
• Other UB04 Claim Form Codes

Note: Medicare has different instructions for Rural Health Clinics and Federally Qualified Health Centers. To view those instructions, click HERE. Then, under “manual” select “100-04 Medicare Claims Processing Manual” and then under “chapter,” select “Chapter 9  Rural Health Clinics/ Federally Qualified Health Centers.”

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