Get Ub-04-claim-form-requirements-utah 20120101.docx

The CMS-1450 form (aka UB-04 at present) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

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).

The UB-04 is maintained by NUBC, which is a voluntary and multidisciplinary committee that develops data elements for claims and claim-related transactions and is responsible for the design and printing of the current UB-04 form.

On an institutional claim, a 4-digit code in box 4 identifies the type of facility, type of care, and the frequency code is generated based on parameters set under the office settings and attached to a patient's claim.

The UB-04 claim form is used to submit claims for outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics and chronic dialysis centers).

All institutional providers may use the UB-04 form to bill claims, such as hospitals, specialists, mental health centers, hospices, rehabs, organ procurement organizations and therapy services.

UB-04 Claim Form Instructions Please note that payment rules can change frequently for any payer. The National Uniform Billing Committee (NUBC) maintains the lists of approved codes for the form.

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.