UB 04 Clean claim submission
The UB-04 form (previously known as the UB-92 and CMS-1450 claim forms) captures essential data elements for providers of services in institutional/inpatient/facility settings. The form can be used to bill Medicare fiscal intermediaries, Medicaid state agencies and health plans/insurers. The required elements of a clean claim must be complete, legible and accurate.
In the following line item description, the parenthetical information following each term is a reference to the field number to which that term corresponds on the UB-04 claim form.
• Provider’s name, address and telephone number (field 1);
• Patient control number (field 3);
• Type of bill code (field 4);
• Provider’s federal tax ID number (field 5);
• Statement period (beginning and ending date of claim period) (field 6);
• Patient’s name (field 8);
• Patient’s address (field 9);
• Patient’s date of birth (field 10);
• Patient’s gender (field 11);
• Date of admission (field 12);
• Admission hour (field 13);
• Type of admission (e.g. emergency, urgent, elective, newborn) (field 14);
• Source of admission code (field 15);
• Patient-status-at-discharge code (field 17);
• Value code and amounts (fields 39-41);
• Revenue code (field 42);
• Revenue/service description (field 43);
• HCPCS/Rates (current CPT or HCPCS codes are required) (field 44);
• Service date (field 45), (required for each date of facility-based non-inpatient services or itemization in a separate attachment is required);
• Units of service (field 46);
• Total charge (field 47);
• HMO or preferred provider carrier name (field 50);
• Type 2 main NPI number (field 56);
• Subscriber’s name (field 58);
• Patient’s relationship to subscriber (field 59);
• Insured’s Unique ID (field 60);
• Principal diagnosis code (ICD-10 codes are required effective 10/1/15) (field 67);
• Rendering provider Type 1 NPI (field 76-79); and
• Attending physician ID (field 76-79).
Data elements: Unless otherwise agreed by contract, the data elements contained in this paragraph are necessary for claims filed by physicians or providers if circumstances exist which render the data elements applicable to the specific claim being filed. The applicability of any given data element contained in this paragraph is determined by the situation from which the claim arose.
(1) Discharge hour (UB-04, field 16), is applicable if the patient was an inpatient, or was admitted for outpatient observation;
(2) Condition codes (UB-04, fields 18-28 are applicable if the CMS UB-04 manual contains a condition code appropriate to the patient’s condition;
(3) Occurrence codes and dates (UB-04, fields 31-34), are applicable if the CMS UB- 04 manual contains an occurrence code appropriate to the patient’s condition;
(4) Occurrence span code, from and through dates (UB-04, field 36), is applicable if the CMS UB-04 manual contains an occurrence span code appropriate to the
patient’s condition;
(5) HCPCS/Rates (UB-04, field 44), is applicable if Revenue Code description used does not adequately describe service provided or if Medicare is a primary or
secondary payer;
(6) Prior payments – payer and patient (UB-04, field 54), is applicable if payments have been made to the physician or provider by the patient or another payer or
subscriber, on behalf of the patient or subscriber, or by a primary plan;
(7) Diagnoses codes other than principle diagnosis code (UB-04, fields 67), is applicable if there are diagnoses other than the principle diagnosis and ICD-10
code is required effective 10/1/15;
(8) Ambulance trip report, submitted as an attachment to the claim; and
(9) Anesthesia report is applicable to report time spent on anesthesia services.