The ub04s are similar to the cms or hcfa 1500 forms, but used by hospitals and clinics rather than physician or other provider services. Sample ub 04 forms for inpatient and outpatient claims can be found on pages 3 and 4. The form cms1450, also known as the ub 04, is the standard claim form to bill medicare administrative contractors macs when a paper claim is allowed. See also claim frequency code in this documentation. Ub04 claim form instructions health insurance claim form 0418 field no. Ub04 claim form instructions form locator name instructions 1. See org for more information on ub04 data element and printing. Report all services provided on the right day for patients who only use 1 application form to ensure appropriate benefit coverage. Ub 04 fill out and sign printable pdf template signnow. 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. Kareo guide to ub04 form last updated dec 18, 2018.
The ub 04 form serves as a show of room bills and summarizes the prices of all patient health care services provided at the right time to assess their care. Dialysis clinics, nursing homes, freestanding birthing centers, residential treatment centers, and hospice services also are billed on the ub04 claim form. The ub04 cms 1450 is a claim form used by hospitals, nursing facilities, inpatient, and other facility providers. On a noncolor printout, required fields will appear darkest. The fillable pdf template for the ub04 health insurance claim form also known as the cms 1450 allows the user to create and save unlimited claims. Ub 04 claim form this document explains the ub 04 claim form, which is used for submitting claims for reimbursement for specially designated facilities. Pay to address pay to address if different than field 1. Billing provider and recipient information section must be completed as indicated on the claim. Sample ub04 forms for inpatient and outpatient claims can be found on pages 4 and 5.
Nov 15, 2016 these colors are needed to enable automated reading of information on the form. The form cms1450, also known as the ub04, is the standard claim form to bill medicare administrative contractors macs when a paper claim is allowed. Section 1 cms1500 paper claim billing instructionsfield locators multiple page claims when billing a multiple page claim, you must indicate page x of y in box 19, local use of the cms1500 claim form. The members of the nubc endorsed the ub82 as the uniform bill. Champva application for benefits, va form 1010d fillable pdf. Inpatient hospital facilities, such as medicalsurgical intensive care, burn care, coronary care and ancillary charges such as labor and delivery, anesthesiology and. These colors are needed to enable automated reading of information on the form. Identifier npi and has incorporated other important changes. Patient control number enter your facilitys unique account number.
The accurate completion of claims documentation is the responsibility of the healthcare provider. The ub 04 claim form and npi the ub 04 claim form includes several fields that accommodate the use of your npi. Sample ub04 forms for inpatient and outpatient claims can be found on pages 3 and 4. All establishments that can be classified as medical institutions must bill medical claims by filing ub04 cms1450 forms, which has become the standard form requested by insurance. You can find medicare cms1450 ub 04 completion and coding instructions in chapter 25 of the medicare claims processing manual pub. The ub 04 is a uniform institutional bill suitable for use in billing multiple third party liability tpl payers. The ub04 claim form may be used by institutional healthcare providers for submitting insurance claims. The focus then shifted to the state level for implementation of the ub82.
The ub 82 format and data specifications were finalized at the may 1982 nubc meeting. The form is aligned to place the text in the proper spaces. Intermediate care facilitiesaddictions services are billed on a ub 04. Ub 04 claim form instructions form locator name instructions 1. When submitting claims on the ub04 for medicare deductible andor coinsurance this medicare attachment must be completed and submitted with the ub04 claim form. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. New ub04 cms 1450 claim instructions for personal care. Inside is a blank ub04 claim form for reference, and information on medicas. Ub04 facility claim form instructions this guide is designed to be used as a reference tool for our claim submitters to provide the expected content of each field on the ub04, the standard paper claim form for facility claims. Ub 04 pdf insurance claim form filler free download and.
The form has numbered entries called form locators that require specific information necessary to process an insurance claim. Wisconsin medicaid will continue to accept the ub92. Overview of the ub04 billing claim form verywell health. The ub04 claim form accommodates the national provider. Ub04 claim form this document explains the ub04 claim form, which is used for submitting claims for reimbursement for specially designated facilities. The cms 1500 claim form must be completed for all professional medical services, and the ub 04 claim form must be completed for all facility claims. The 7digit medicaid provider number previously entered in the ub92 form locator 51 must be entered here.
Please do not staple or paper clip this form to the claim. All claims must be submitted within the required filing deadline of 120 days from the date of service unless a good cause exception as defined herein applies. Claims with type of bill 011x, 018x, 021x, or 032x are exempt from this rule. Medical billing uses threedigit codes on a claim form to describe the type of bill a provider is submitting to a payor. This ub 04 guide was developed specifically to assist providers with completing the new ub 04 claim form during the dual identifier acceptance phase. Dialysis clinics, nursing homes, freestanding birthing centers, residential treatment centers, and hospice services also are billed on the ub 04 claim form. Iowa medicaid enterprise ub04 claim form instructions. Ub 04 claim form instructions health insurance claim form 04 18 field no. The 3digit code includes a twodigit facility type code followed by a onecharacter claim frequency. Provider handbook 837 institutionalub04 claim form ub04 billing guide for promise inpatient hospitals provider handbook ub04 july 12, 2018 4 form locator number form locator name form locator code notes 3. Enter the date the claim is created in mmddyy format. You can find medicare cms1450 ub04 completion and coding instructions in chapter 25 of the medicare claims processing manual pub.
The ub 04 claim form is used to bill for all hospital inpatient, outpatient, and emergency room services. Also known as the cms1450 form, this is the industry standard for paper billing of all insurance carriers. The members of the nubc endorsed the ub 82 as the uniform bill. Ub 04 form fill online, printable, fillable, blank pdffiller. Ub 04 claim form e december 2018 3 ub 04 claim form description the ub 04 claim form is used to request reimbursement for services rendered by the following institutions. New ub04 claim form completion instructions providers should use the instructions in attachment 1. The modifier would be reported on the ub04 form cms form owcp04 us department of labor. The ub04 module is only used in cases involving medical therapy. Health insurance claim forms fiachra forms charting solutions.
Health insurance claim forms fiachra forms charting. Inside is a blank ub 04 claim form for reference, and information on medica s requirements for successful completion of the ub 04 claim form. Ub04 form is used by institutional providers, like hospitals, rehabilitation facilities, home health agencies, therapy services, etc. They are not required on inpatient hospital claims. If you dont want to file online, download the form you need by visiting. Completing the ub04 claim form guidelines for facility. Dates of service are required for outpatient hospital services. The ub04 claim form must be completed for all facility claim submissions including home health agency. Consider our billing package that includes 200 or 500 paper. The ub82 format and data specifications were finalized at the may 1982 nubc meeting. The ub04 pdf template is designed to print just the typed text on a commercially printed claim form.
Ub04 cms1450 form filler software, allows you to fill out ub04 forms on your pc. The ub04 claim form and npi the ub04 claim form includes several fields that accommodate the use of your npi. Independence blue cross ub04 claims submission guide. Ub04, the abbreviation for uniform invoicing, is a way to fill out a form that must be. Each digit has a specific purpose and is required on all ub 04 claims.
Sample cms1450 ub04 claim form outpatient hospital cms1450 ub04 claim form1 a a b b c d d e e f f g g h h this sample form is provided for informational purposes only. If left blank, will default to first date of service. Ub 04 instructions and sample claim form last updated on january 24, 2019 any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. When submitting the above claims, complete all items required by each payer who is to receive a copy of the form. Identify the section in the provider manual related to ub04 claim form completion. Further information on the ub04 is available through the nubc web site. Instructions for completing the ub04 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. Visit the institutional paper claim form cms1450 web page for. In addition to billing medicare, the 837i and form cms1450 may be suitable for billing various government and some private insurers. To indicate the conclusion of the entire claim, field 28 of the last page of. Support we have a friendly and courteous staff that is available by phone 7.
Our ub 04 software has more features than any other software on the market and is designed to make your ub 04 form claim processing as simple, fast and reliable as possible. May 01, 2018 this form can be found on the form page on the medical site. Ub04 claim form e december 2018 3 ub04 claim form description the ub04 claim form is used to request reimbursement for services rendered by the following institutions. Ub 04 form fill online, printable, fillable, blank. Sample ub 04 forms for inpatient and outpatient claims can be found on pages 4 and 5. Ub04 data field requirements independence blue cross. Start a free trial now to save yourself time and money. This ub04 guide was developed specifically to assist providers with completing the new ub04 claim form during the dual identifier acceptance phase. Sample cms1450 ub 04 claim form outpatient hospital cms1450 ub 04 claim form1 a a b b c d d e e f f g g h h this sample form is provided for informational purposes only. Fill out, securely sign, print or email your ub 04 form sample instantly with signnow. When submitting claims on the ub 04 for medicare deductible andor coinsurance this medicare attachment must be completed and submitted with the ub 04 claim form. There are two standard forms designed by the cms centers for medicare and medicaid for billing claims. Ub04 billing claim form, also known as the cms1450 form, is the universal paper claim used to bill for medical and mental health services.
Field name description requirements instructions 1 untitled provider name, address and telephone number required enter the name, address and phone number of the billing facility or service supplier. Put a commercially printed ub04 paper claim in the printer. At the time of original publication, this reference document was accurate and uptodate in accordance with the centers for medicare and medicaid services cms requirements. The focus then shifted to the state level for implementation of the ub 82. Only the instructions for form locators required for dxc technology processing or for medicaid program information are included. These instructions include specifications for each form locator field on the ub04 claim form and whether or not medica requires the field be completed. Ub04 claim form instructions geisinger health plan. These two forms appear and function in the same way, but they cannot be exchanged. Ub 04 billing claim form, also known as the cms1450 form, is the universal paper claim used to bill for medical and mental health services. Each digit has a specific purpose and is required on all ub04 claims. A ub04 with field descriptions and instructions is included in the link below.
Ub 04 form pdf fill out and sign printable pdf template. The ub04 module is only used to involve medical therapy. The ub 04 cms 1450 is a claim form used by hospitals, nursing facilities, inpatient, and other facility providers. These instructions include specifications for each form locator field on the ub 04 claim form and whether or not medica requires the field be completed. Ub 04 cms1450 form filler software, allows you to fill out ub 04 forms on your pc. The ub04 claim form is used to bill for all hospital inpatient, outpatient, and emergency room services.
The 7digit medicaid provider number previously entered in the ub 92 form locator 51 must be entered here. Although the form accommodates the npi, you may continue to report your current provider identification numbers in the appropriate areas of the form. If you have any questions regarding the ub04 claim form, please call your. Ub04 instructions and sample claim form last updated on january 24, 2019 any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. The zip code must match the zip code confirmed during. Astellas does not guarantee reimbursement for any services or products. Enter the 7digit numeric provider identification number which was assigned by the medicaid program in 57a. Ub04 ub92 and ub04 forms are medical insurance claim forms used by facilities such as hospitals, inpatient and outpatient clinics and ambulatory surgery centers to bill insurance companies for services rendered. Inside is a blank ub04 claim form for reference, and information on medica s requirements for successful completion of the ub04 claim form. Cms form 1500 and cms form ub04, also known as cms1450.