You can access the ub04 billing information adopted by the nubc by. Aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare. Responsible party name and address required if applicable 3941 value codes and amounts required if applicable value codes identify special circumstances that may affect the processing of the claim. The nubc official ub04 data specifications manual includes a number of questions and answers related to the appropriate use of these codes. Enter the appropriate condition codes that apply to this bill. Point of origin and discharge status codes for designated disaster alternate care sites. The instructions included in this section are excerpts from medicare instructions rev. National uniform billing committee nubc update to chapter 25 i. Admission or visit codes to the ub04 cms1450 manual code list. Enter the appropriate threecharacter type of bill code as specified in the national uniform billing committee nubc ub04 data specifications manual. This form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing. Medicare lifetime reserve amount in the second calendar year in billing period. Cmcm providers who choose to submit their claims on paper forms must use the national uniform billing committee nubc ub04 claim form.
The official source of ub04 billing information adopted by the national uniform billing committee nubc. Ub04 hospital billing instructions and matric revenue code. This manual, ed by the american hospital association, is the only official source of ub data. Tips for completing the ub04 cms1450 claim form revised 04. New value code methodology contained in the 2018 ub04 manual appendix will be implemented for paper claims only august 9, 2017 meeting minutes 1119 fl 3941. Point of origin codes update to the ub04 cms1450 manual code list national uniform billing committee nubc, will be accepted into the fiscal 3 elective the patients condition permitted adequate time to schedule the. Home health rural addon payments based on county of cms. The provider uses this code only on bills spanning 2. Required when there is a condition code that applies to this claim. Dec 31, 2018 january 1, 2019, the claim contains the code for the county or copies or utilizing the content of the ub04 manual, including the codes andor. For information on the ub04 billing form, or to obtain an official ub04 data specifications manual, visit the national uniform billing committee nubc web site at. Please refer to the manual for detailed\ answers to billing questions. New value code for county where service was rendered april 17, 2018 meeting minutes 4119 fl 3941. The following fields have been updated to match the fields in the nubc manual.
Ub04 instructions aug 27, 2010 value codes and corresponding amountsdays. Billing code 412001p department of health and human jul 31, 2018 the search instructions on that website to view public comments. Quest integration instructions for completing the ub04 claim form. The national uniform billing committee nubc is responsible for the design. National uniform billing committee nubc and to cms manual system. Fl 1828 condition codes 65 fl 29 accident state 81 fl 30 reserved for assignment by the nubc 82 fl 34 occurrence codes and dates 83 fl 3536 occurrence span codes and dates 92 fl 37 reserved for assignment by the nubc 96 fl 38 responsible party name and address claim addressee 97 fl 3941 value codes and amounts 98. National uniform billing committee nubc and to medicare claims processing manual crosswalk cms.
Form cms1450 ub04 this form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. Entry must be three digits and must be placed to the left of the dollarscents delimiter. The hospital reports right justified in the cents area. R761otn pdf, 16mb cms location of b75xx if the reason code is to send a claim to the post pay driver 06 foster child. Billing committee nubc official ub04 data specifications manual.
Apr 1, 2004 cms1450, is being updated to include new condition and value codes approved by the. Nov 10, 2014 for cy 2015 to implement applicable statutory hcpcs codes identified in addenda b. Please use the national ub04 manual for specific codes. Shield of texas offers this guide to help you complete the ub04 form for your patients with blue cross facility coverage. The displayed claim form is a sample and is for illustration purposes only. National uniform billing committee official data specifications manual. Nov 16, 2018 processing standards fips state and county codes lists. Sep 2, 20 20 national uniform billing committee nubc ub04 code changes. The national uniform billing committee nubc designates various series within the condition, occurrence, occurrence span and value codes as payer only codes. R3435cp 12312015 clarification on patients reason for visit. Aug 4, 2015 o ub04 value code maintenance update attachment 4 2016 meeting planning.
The value code and remittance advice amounts are different. Patient discharge status \2 positions, numeric\\r\rrequired\r\rnote. September 20 anthem sep 2, 20 20 national uniform billing committee nubc ub04 code changes. For part b coinsurance use value codes a2, b2 and c2. Mar 9, 2010 changes for condition code 47 used to replace code b are also. New ub04 codes will be implemented according to an annual. No other publication governmental or privatecommercial can be considered authoritative. Medicare hospital outpatient bills list every service by hcpcs code. Because it serves many payers, a particular payer may not need some data elements. This guide contains nevada medicaid specific instructions related national uniform billing committee nubc. Home health rural addon payments based on county cms. Ub04 billing instructions guide health pasonline maine. Ub04 claim form this document explains the ub04 claim form, which is used for submitting claims for reimbursement for specially designated facilities. Apr 02, 2015 aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare pdf download medicare benefits pdf download.
Revenue codes are required for instance, for organ procurement for select op billing. Chapter 25 completing and processing the form cms1450 data set. This manual, ed by the american hospital association, is the only. Ub04 change implementation calendar effective date. Dec 4, 2018 identify the section in the provider manual related to ub04 claim form completion icd10cm diagnosis codes and icd10 pcs codes on a claim to ensure payment at the nubc ub04 data specifications manual. Select the appropriate code from the nubc ub04 manual. F245425000 072015 revenue codes requiring cpt hcpcs codes on outpatient bills. Hmsa has determined that it will use the national uniform billing committee nubc official ub04 data specifications manual as the standard source for codes and code descriptions to be entered in the various form locators fl. Nubc maintains lists of approved coding for the form. Fl 30 reserved for assignment by nubc 32 fl 34 occurrence codes and dates 32 fl 3536 occurrence span codes and dates 36 fl 37 not used 38 fl 38 responsible party name and address 38 fl 3941 value codes and amounts 38 fl 42 revenue codes 42 fl 43 national drug code ndc reporting 43 fl hcpcs44 accommodation rateshipps rate codes 45. Medicaids expanded modified field must contain a valid nubc code. Ub04 for outpatient services section in this manual. The ub04 is the replacement for the ub92 form and represents the culmination of a fouryear study that involved numerous public surveys and discussions at various nubc meetings. Occurrence span codes and dates required if applicable 38.
The 2021 edition contains the updated specifications for the data codes included on the uniform bill claim form. Please refer to the manual for detailed\ answers to. The product of the number of lifetime reserve days used in the second calendar year of the billing period multiplied by the applicable lifetime reserve rate. Locator codes 001 and 002 are for administrative use only and are not to be entered in this field. Frequency codes position 4 value 7 and 8 will not be processed as an adjustment or void. The official ub04 data specifications manual 2020, ed by the american hospital association, is the only official source of ub04 billing information adopted by the national uniform billing committee nubc.
Enter a code indicating patient status as of the ending service date of the period covered on the bill, as reported in fl 6, statement covers period. The following instructions explain how to complete the ub04 claim form and whether a field is required. Identify the section in the provider manual related to ub04 claim form completion. Changes include definition changes for value codes 48 and 49, deletion of ub92 information, removal of periods. Point of origin codes update to the ub04 cms1450 manual code list national uniform billing committee nubc, will be accepted into the fiscal. Quest integration instructions for completing the ub04. All code values listed in the nubc ub04 reference manual for each form locator ub04 claim form medical. This value or value 58 is required on the initial bill for oxygen therapy and on the fourth months bill. National uniform billing committee nubc and to ub04 billing guide inpatient hospitals 02017. No other publicationgovernmental or privatecommercialcan be considered authoritative. Hospice medicare billing codes sheet cgs administrators. Nys medicaid uses value codes to report the following information.
To view a sample cmcm ub04 claim form, see appendix a. Enter up to four code s and associated dates for any significant events that may affect processing. Chapter 25 is being updated to reflect approved nubc changes. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. Aarp health insurance plans pdf download medicare replacement pdf download medicare benefits pdf download medicare part b pdf download nubc value codes.
This section contains medicare requirements for use of codes maintained by the nubc. Changes include definition changes for value codes 48 and 49, deletion of ub92 information. Blue shield of new mexico offers this guide for completion of the ub04 form for your patients with blue cross facility coverage. Uniform billing committee nubc at its february 2005 meeting. The ub04 claim form is a hardcopy facility claim form used for facility claims filing.