For a successful medical practice, it is imperative to have a robust medical billing process in place. Although billing and coding is a challenging procedure, understanding and streamlining the process in order to have complete reimbursement is, however, a bit critical. Nevertheless, filing an error-free claim is the first step in receiving a complete settlement.
The Centers for Medicare and Medicaid Services (CMS) has developed a new, universal claim form for medical billing. The form is used by physicians and other healthcare professionals to bill for services provided to Medicaid beneficiaries.
Healthcare practices use the two most common claim forms to file reimbursement claims i.e., UB-04 ad CMS-1500
What is a UB-04 Form in medical billing?
A UB-04 form is a standardized medical claim form used in the United States. It is used to bill for services provided by hospitals, skilled nursing facilities, home health agencies, hospices, and other health care providers.
The UB-04 form is a common medical billing form that is used to submit claims to insurance companies. The form includes patient information, diagnosis codes, procedure codes, and other relevant information. A number of medical facilities can use this form for claim filing, including;
Who can bill claims using the UB-04?
- Critical access hospitals
- Community mental health centers
- Home health agencies
- End-stage renal disease facilities
- Hospices
- Organ procurement organizations
- Indian Health Services facilities
- Occupational therapy services
- Rural health clinics
- Religious non-medical healthcare institutions
- Speech pathology services
- Outpatient physical therapy services
- Hospitals
- Comprehensive outpatient rehabilitation facilities
- Federally qualified health centers
- Histocompatibility laboratories
Tips for filing the UB-04 form accurately
Here are some specific things to ensure while filing the UB-04 claim form to avoid mistakes and errors;
- Double-check all the information that could be different according to each insurance provider.
- Make sure that the data filled in all the sections of the claim form is correct and added correctly.
- Ensure that the patient information matches exactly as it is written on the insurance card.
- Affirm that the CPT/ICD/HCPCS codes are not overly used and the claim is free from duplicate entries.
- Always use the physical address for the field in the facility location
- Don’t forget to add National Provider Identifier (NPI) number where required.
Fields of UB-04 to fill accurately
A total of 81 fields are there in a UB-04 claim form, which is called FL or form locators. Here’s why they are referred to as FL;
- Form locator 1: Billing provider name, street address, city, state, zip, telephone, fax, and country code
- Form locator 2: Billing provider’s pay-to name, address, city, state, zip, and ID if it’s different from field 1
- Form locator 3: Patient control number and the medical record number for your facility
- Form locator 4: Type of bill (TOB). According to the National Uniform Billing Committee guidelines, this is a four-digit code beginning with zero.
- Form locator 5: Federal tax number for your facility
- Form locator 6: Statement from and through dates for the service covered on the claim in MMDDYY (month, date, year) format.
- Form locator 7: Number of Administratively Necessary Days
- Form locator 8: Patient name in Last, First, MI format
- Form locator 9: Patient street address, city, state, zip, and country code
- Form locator 10: Patient birth date in MMDDCCYY (month, day, century, year) format
- Form locator 11: Patient sex (M, F, or U)
- Form locator 12: Admission date in MMDDCCYY format
- Form locator 13: Admission hour using a two-digit code from 00 for midnight to 23 for 11 p.m.
- Form locator 14: Type of visit: 1 for an emergency, 2 for urgent, 3 for elective, 4 for newborn, 5 for trauma, 9 for information not available.
- Form locator 15: Point of origin (source of admission)
- Form locator 16: Discharge hour in the same format as line 13.
- Form locator 17: Discharge status using the two-digit codes from the NUBC manual.
- Form locator 18-28: Condition codes using the two-digit codes from the NUBC manual for up to 11 occurrences.
- Form locator 29: Accident state (if applicable) using a two-digit state code
- Form locator 30: Accident date
- Form locator 31-34: Occurrence codes and dates using the NUBC manual for codes
- Form locator 35-36: Occurrence span codes and dates in MMDDYY format
- Form locator 37: Not in use
- Form locator 38: Responsible party name and address
- Form locator 39-41: Value codes and amounts for special circumstances from the NUBC manual
- Form locator 42: Revenue codes from the NUBC manual
- Form locator 43: Revenue code description, investigational device exemption (IDE) number, or Medicaid drug rebate NDC (national drug code)
- Form locator 44: HCPCS (Healthcare Common Procedure Coding System), accommodation rates, HIPPS (health insurance prospective payment system) rate codes
- Form locator 45: Service dates
- Form locator 46: Service units
- Form locator 47: Total charges
- Form locator 48: Non-covered charges
- Form locator 49: Page_of_ and Creation date
- Form locator 50: Payer Identification (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 51: Health plan ID (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 52: Release of information (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 53: Assignment of benefits (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 54: Prior payments (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 55: Estimated amount due (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 56: Billing provider national provider identifier (NPI)
- Form locator 57: Other provider ID (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 58: Insured’s name (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 59: Patient’s relationship (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 60: Insured’s unique ID (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 61: Insurance group name (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 62: Insurance group number (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 63: Treatment authorization code (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 64: Document control number also referred to as Internal control number (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 65: Insured’s employer name (a) Primary, (b) Secondary, and (c) Tertiary
- Form locator 66: Diagnosis codes (ICD)
- Form locator 67: Principle diagnosis code, other[1] diagnoses, and present on-admission (POA) indicators
- Form locator 68: Not in use
- Form locator 69: Admitting diagnosis codes
- Form locator 70: Patient reason for visit codes
- Form locator 71: Prospective payment system (PPS) code
- Form locator 72: External cause of injury code and POA indicator
- Form locator 73: Not in use
- Form locator 74: Other procedure code and date
- Form locator 75: Not in use
- Form locator 76: Attending provider NPI, ID, qualifiers, and last and first name
- Form locator 77: Operating physician NPI, ID, qualifiers, and last and first name
- Form locator 78: Other provider NPI, ID, qualifiers, and last and first name
- Form locator 79: Other provider NPI, ID, qualifiers, and last and first name
- Form locator 80: Remarks
- Form locator 81: Taxonomy code and qualifier
What is a CMS-1500?
The CMS-1500 is a standard claim form used by healthcare providers to bill Medicare and other insurance carriers. The form is designed to streamline the billing process and provide necessary information for insurers to process claims quickly and accurately.
The CMS-1500 must be completed in full and submitted to the insurer along with any supporting documentation. The form includes sections for the patient’s personal information, the provider’s information, the service dates and codes, and the diagnosis codes.
The CMS-1500 form is used for billing for a variety of services, including doctor’s visits, hospital stays, laboratory tests, and other outpatient procedures. The form is also used to request reimbursement for expenses such as mileage, supplies, and office visit co-pays.
The CMS-1500 form must be filled out correctly in order to be processed by Medicare and other insurers. Only complete or accurate forms may be returned to the provider, which could delay or prevent payment.
Things to consider when filing claim forms
Filing an insurance claim form may seem like a simple task, but there are actually a few things you should keep in mind to make sure the process goes smoothly. Here are a few things to consider when filing insurance claim forms:
Make sure you have all the required information. This includes your policy number, the date of treatment, and a detailed description of medical healthcare information.
Once the claim form is filled, it will be scanned through Optical Character Recognition or OCR. This will fade out all the red-colored printing from the form and leave the filled area. This is why it is suggested to fill the form with black ink or avoid filling manually.
What is the difference between the UB-04 and the CMS 1500 claim forms?
The UB-04 and CMS 1500 are two of the most commonly used medical claim forms. They are both used to submit claims to insurance companies for reimbursement of medical services.
The UB-04 form is generally used for institutional service providers, like hospitals, nurses, medical professionals, etc. Whereas, the CMS 1500 form is used for non-institutional services like medical equipment providers. The CMS 1500 form is also used for some types of outpatient services, such as home health care and durable medical equipment.
The UB-04 form is more complex than the CMS 1500 form, and it requires more information about the patient and the services rendered. The CMS 1500 form is less complex and requires less information.
Both forms are available online, and they can be downloaded and printed for free.
Who develops data reports for UB-04 claim form?
The UB-04, also known as the CMS-1450, is a standardized claim form used by hospitals and other medical facilities to bill for services. The form includes a series of data elements that must be completed in order to process the claim.
But who is responsible for developing the data elements that are reported on the UB-04? The answer may surprise you. According to the Centers for Medicare and Medicaid Services (CMS), the data elements on the UB-04 are developed by the National Uniform Billing Committee (NUBC). The NUBC is a non-profit organization that is made up of representatives from the American Hospital Association (AHA), the American Medical Association (AMA), and the Centers for Medicare and Medicaid Services (CMS).