The UB-04 form is the standard claim form used by institutional providers to bill Medicare, Medicaid, and other insurance payers for services. Accurately completing all fields, especially those related to provider type and national provider identifiers (NPI), is crucial for timely processing and reimbursement. This guide provides detailed instructions on how to fill UB-04 provider type fields 55-56 and the essential NPI requirements for fields 76, 77, and 56, ensuring your institutional claims meet current guidelines and avoid common errors.
FL 55-56: Provider Type Codes – Identifying Institutional Providers
This section identifies institutional providers that require special handling. Enter one of the following codes as appropriate. Understanding these codes is key to proper **how to fill UB-04 provider type** fields.
| Code | Provider Type Description | Notes/Effective Dates |
|---|---|---|
| 00 or blanks | Short Term Facility | Typically acute care hospitals for short stays. |
| 02 | Long Term Facility | Providers offering extended care services. |
| 03 | Psychiatric Facility | Inpatient psychiatric hospitals. |
| 04 | Rehabilitation Facility | Inpatient rehabilitation facilities. |
| 05 | Pediatric Facility | Hospitals specializing in pediatric care. |
| 06 | Hospital Distinct Parts | Effective until July 1, 2006. After this date, provider type “06” is no longer used. Instead, distinct parts of hospitals are assigned specific provider types (49-54). **Current claims must use the appropriate codes 49-54 for distinct part facilities.** |
| 07 | Rural Referral Center | |
| 08 | Indian Health Service | |
| 13 | Cancer Facility | |
| 14 | Medicare Dependent Hospital | During cost reporting periods that began on or after April 1, 1990. |
| 15 | Medicare Dependent Hospital/Referral Center | During cost reporting periods that began on or after April 1, 1990. Invalid October 1, 1994, through September 30, 1997. |
| 16 | Re-based Sole Community Hospital | |
| 17 | Re-based Sole Community Hospital /Referral Center | |
| 18 | Medical Assistance Facility | |
| 21 | Essential Access Community Hospital | |
| 22 | Essential Access Community Hospital/Referral Center | |
| 23 | Rural Primary Care Hospital | |
| 32 | Nursing Home Case Mix Quality Demonstration Project – Phase II | |
| 33 | Nursing Home Case Mix Quality Demonstration Project – Phase III – Step 1 | |
| 34 | Reserved | |
| 35 | Hospice | |
| 36 | Home Health Agency | |
| 37 | Critical Access Hospital | |
| 38 | Skilled Nursing Facility (SNF) | For non-demo PPS SNFs – effective for cost reporting periods beginning on or after July 1, 1998. |
| 40 | Hospital Based ESRD Facility | End-Stage Renal Disease facility. |
| 41 | Independent ESRD Facility | End-Stage Renal Disease facility. |
| 42 | Federally Qualified Health Centers | |
| 43 | Religious Non-Medical Health Care Institutions | |
| 44 | Rural Health Clinics-Free Standing | |
| 45 | Rural Health Clinics-Provider Based | |
| 46 | Comprehensive Outpatient Rehab Facilities | |
| 47 | Community Mental Health Centers | |
| 48 | Outpatient Physical Therapy Services | |
| 49 | Psychiatric Distinct Part | |
| 50 | Rehabilitation Distinct Part | |
| 51 | Short-Term Hospital – Swing Bed | |
| 52 | Long-Term Care Hospital – Swing Bed | |
| 53 | Rehabilitation Facility – Swing Bed | |
| 54 | Critical Access Hospital – Swing Bed |
FL 76: Attending Provider Name and Identifiers on UB-04 Claims
This field is used to identify the individual attending provider. The Universal Provider Identification Number (UPIN) was a legacy identifier previously required for providers. The UPIN was required on inpatient Part A bills with a “Through” date of January 1, 1992, or later, and for outpatient and other Part B services with a “From” date of January 1, 1992, or later. This requirement applied to all provider types and Part B bill types.
However, **effective May 23, 2007**, the UPIN was officially replaced by the National Provider Identifier (NPI) as the standard identifier. NPI is now the current and required identifier for all institutional claims. You can verify NPI details through the official NPI Registry.
Generally, an institutional provider may not submit their own NPI in FL 76, as this field is designated for the individual attending provider. However, specific exceptions allow for the institutional billing NPI under certain circumstances. These include:
- Institutional billing of influenza and pneumococcal vaccinations and their administration as the only billed service on a claim.
- Roster billing of influenza and pneumococcal vaccinations and their administrations.
- Self-referred screening mammography as the only billed service on a claim.
- When the provider only has a Type 1 NPI as a physician/practitioner-owned sole-proprietor for institutional billing.
FL 77: Operating Physician NPI Requirements for Institutional Claims
This field is critical for identifying the operating physician on institutional claims. Effective **May 23, 2007**, providers are required to submit the NPI for the operating physician. Adhering to **UB-04 field 77 operating physician NPI** guidelines is essential for accurate claim processing and compliance.
NPI must be present in FL 77 if:
- Bill type is 11X and a procedure code is shown in FL 74.
- Bill type is 83X or 13X and a HCPCS code is reported that is subject to the ASC payment limitation or is on the list of codes the QIO furnishes that require approval.
- Bill type is 85X and a HCPCS code is in the range of 10000 through 69979.
If required, the NPI, last name, and first initial of the operating physician must be present and left-justified in this field.
FL 56: National Provider Identifier (NPI) – Billing Provider
This field requires the NPI of the billing institutional provider. As of **May 23, 2007**, all institutional providers are mandated to submit their NPI in this field. The NPI should be left-justified. Accurate submission of the billing provider’s NPI is fundamental for proper identification and processing of the claim, preventing denials related to provider identification and ensuring compliance with **NPI requirements institutional claims**. For more information on NPI standards, refer to official CMS NPI guidelines.
Frequently Asked Questions (FAQs) on UB-04 Provider Types and NPI
- Q: What is the primary purpose of Provider Type codes in FL 55-56?
- A: Provider Type codes in FL 55-56 are used to identify institutional providers that require specific handling or classification, ensuring claims are processed according to the payer’s rules for that particular facility type. Accurate coding helps to prevent claim rejections.
- Q: Why was UPIN replaced by NPI, and when did this change occur?
- A: The Universal Provider Identification Number (UPIN) was replaced by the National Provider Identifier (NPI) to standardize provider identification across all health plans and simplify administrative processes. This transition officially took effect on **May 23, 2007**, making NPI the mandatory identifier.
- Q: Can an institutional provider use its own NPI in FL 76 (Attending Provider)?
- A: Generally, no. FL 76 is for the individual attending provider’s NPI. However, exceptions exist, such as for institutional providers who only have a Type 1 NPI as a physician/practitioner-owned sole-proprietor, or for specific services like vaccinations or screening mammography when billed under certain conditions.
Conclusion: Ensuring Accurate UB-04 Claim Submission
Accurate and up-to-date completion of the UB-04 claim form, particularly the provider type codes in FL 55-56 and National Provider Identifiers (NPI) in fields 76, 77, and 56, is paramount for institutional providers. Adhering to the latest guidelines helps avoid claim denials, ensures timely reimbursement, and maintains compliance with federal regulations. Regularly reviewing official **CMS UB-04 guidelines** and NPI requirements is essential for successful billing operations.