Claim Form Billing Instructions UB-04 Claim Form

ACS publication for NM Medicaid Fee-for-Service Program UB-04 Instructions First Publication Date: 3/6/2007 Current Revision Date: 4/27/2007

Form Locator (FL) Number

Required Field?

1

Required

2 3a 3b 4 5 6

Situational Optional Optional Required Optional Required

7 8a 8b 9a-9e 10 11 12

--------Required Optional Required Required Situational

13 14 15 16 17

Optional Optional Optional Optional Situational

18-28 29

Optional Optional

30

N/A

Required

Description and Instructions

Billing provider’s name, address and telephone number. This is the street address. The payto address (such as a P.O. Box) is entered in FL 2 Pay-to address: Required if pay-to address is different than physical address Patient Control Number: 20 characters maximum Medical Record Number: 24 characters maximum Type of Bill: must be 3 digits and a valid combination. Federal Tax ID number Statement Covers Period: the beginning and ending services dates for the claim. Enter valid date in mmddccyy format Not used Do not use – not relevant to NM Medicaid Patient name: Last name, first name, middle initial Patient address: 9a-Street, 9b – city, 9c-State, 9d – zip code, 9e – country code Patient date of birth: Enter valid date in mmddccyy format Patient sex: M for male; F for female; U for unknown Admission date: Required for inpatient and hospice claims. Must be valid date format mmddccyy Admission hour: If entered, must be 2-digit value of 00-23 or 99 Admission type: If entered must be 1 numeric digit Admission or Visit Referral Source: If entered must 1 numeric digit Discharge Hour: If entered must be 2-digit numeric value of 00-23 or 99 Patient Discharge Status: Required for inpatient, hospice and nursing home claims: Must be valid 2-digit numeric discharge status code. Condition Codes: If entered, condition codes must be a valid 2-digit condition code. Accident State: If the claim is due to an accident, the state where the accident occurred can be entered here using the 2 character state abbreviation. Not used. Leave blank.

Description and Instructions

Form Locator

Required Field?

31-34

Optional

35 & 36

Optional

37 38 39-41

N/A Optional Situtational

42

Required

43

Situational

44

Situational

Description and Instructions Occurrence code and date: If an occurrence code is entered, it must be a valid 2-digit occurrence code. The code can be alpha-numeric. If an occurrence code is entered, a valid date must be present. The date is entered is mmddccyy format. Also note that if a date is entered, a valid occurrence code must be present. Occurrence code and span: If occurrence code is entered, it must be a valid 2-difit occurrence code. The code can be alpha-numeric. If an occurrence code is entered, a valid date span must be present. The dates are entered in mmddccyy format and the “through” date must be greater than the “from” date. Also note that if a date span is entered, a valid occurrence code must be present. Not used. Leave blank. Payer Name and Address Value Codes and Amounts: Inpatient, hospice and long term care claims must enter covered and noncovered days on their claims. Use value code 80 to indicate covered days and 81 to indicate noncovered days. Remember, if a value code is entered, an amount must be entered. Also, the amount entered cannot be all zeroes. Otherwise, if a value code is entered it must be a valid code. “D3” can be used to indicate “patient liability” amount for clients in long term care facilities, but it is not required. Revenue Code: Enter valid 4-digit revenue code (one per line.) Use 0001 to indicate the “total” line after all revenue codes have been listed. Revenue Code Description: Enter standard description for revenue code. NDC codes are required whenever the provider bills one of the following revenue codes and the claim is an outpatient hospital, emergency room facility, dialysis facility, other outpatient facility which uses the UB04 claim form: 1. Pharmacy revenue codes 0250, 0251, 0252, 0254, 0631, 0632, 0633, 0634, 0635, 0636, and 0637. Beginning at the left edge of form locator 43, enter the 2-digit qualifier “N4” immediately followed by the 11-digit NDC. An example of an entry for the NDC code 00054352763 would be: N400054352763. HCPCS/Accommodation Rates: Accommodation rates: Rate can be associated with accommodation revenue codes on inpatient claims can be entered but are not required. HCPCS: HCPCS can be associated with all other revenue codes. A HCPCS code MUST be associated with the revenue code when billed on outpatient claims for the following revenue code ranges: 0320 0329; 0340-0359; 0360-0369; 0400-0409; 0490-0499; and 0610-0619. Up to 2 modifiers can be associated with the HCPCS code entered. Level of Care: Not required. If entered, must be valid 3-character level of care.

45

Optional

46 47

Required Required

48

Situational

49

N/A

Service Date: Not required but recommended, particularly for outpatient claims. Date must be valid format mmddccyy. Date must be within the claim’s from and through dates. Not required for revenue code 0001 totals line. Service Units: Must be numeric and no more than 7 digits. Total Charges: Must be numeric and no more than 11 digits. Amount on revenue code 0001 line must equal sum of charges on all other lines. Non-Covered Charges: Enter non-covered charges when applicable. Total of non-covered charges on revenue code 0001 line must equal sum of non-covered charges on all other lines. Not Used: Leave blank! 3

Form Locator

Required Field?

Description and Instructions

42 (line 23 only) “Page ___ of __” 45 (line 23 only) 47 (line 23 only)

Situational

Revenue Codes (line 23 only): Only “0001” can be in this line as it can be the total line. If the claim is multiple pages, do not put 0001 here. Put it on the last page.

Situational

Total Charges: If “0001” is entered in FL 42, line 23, enter sum of all charges entered on previous lines in FL 47, line 23. Up to 11 numeric digits can be entered. The amount entered must be the sum of all charges entered on previous lines. If “0001” has been entered on another line, do not enter total of all charges in this box. This amount must be entered on the line where “0001” has been entered.

48 (line 23 only)

Situational

Total Non-Covered Charges: If “0001” is entered in FL 42, line 23, enter total of all non-covered charges listed on previous lines in this box. Up to 11 numeric digits can be entered. The amount entered must be the sum of all non-covered charges entered on previous lines. If “0001” has been entered on another line, do not enter total of all non-covered charges in this box. This amount must be entered on the

50a, b & c 51a, b & c 52a, b, & c

Required Not Required Not Required

4

Optional

Completion of this information is recommended for multi-page claims.

Required

Creation Date: This is the “bill date” or the “signature date”. Enter a valid date in mmddccyy format.

line where “0001” has been entered. Payer Name: Enter name of the primary payer on line A, secondary payer on line B, etc. Health Plan ID: This field is for entering the National Health Plan Identifier when it is mandated. Release of Information Certification Indicator: A single-character indicator that signifies whether the provider has a signed release of information statement from the patient.

53a, b & c

Not Required

54a, b, & c

Situational

Assignment of Benefits Certification Indicator: A single-character indicator that signifies whether the provider has a signed form authorizing payment from the payer directly to the provider. Prior Payments: When applicable, enter amount paid by payer associated with line. Do not enter an amount on the Medicaid payer line. If Medicaid has made a payment on the claim and it is either too much or too little, an adjustment must be filed. Do not enter an amount in the Medicare payer line unless billing inpatient Medicare Part A charges for a Part B only recipient. For this, enter the total Medicare paid amount on the Medicare payer line. Attach the Medicare EOMB and enter type of bill 12x (3rd digit as appropriate) in Form Locater 4. If billing a copayment from a private payer or a Medicare Advantage plan, enter an amount equal to the difference between the total charges and the amount of the copayment. Write “HMO copayment” or “Medicare Replacement Plan Copayment” on the claim so that it is easily seen. If coinsurance and/or deductible is due on the third party claim, enter the total amount paid by the third party. If copayment, coinsurance and/or deductible are all due, bill for the lesser amount – the copayment or the coinsurance/deductible.

55a, b &c

Situational

56

Situational

57a, b & c

Situational

Estimated Amount Due: Enter on Medicaid payer line when billing an HMO or PPO copayment. Enter the copayment amount you want to collect. (Please see form locator 54 instructions.) Otherwise, leave blank. NPI: The billing provider’s NPI is REQUIRED if billing provider is a health care provider. Enter the billing provider’s NPI. Otherwise, leave blank. Other Provider ID: If the billing provider is NOT a health care provider, enter Medicaid provider ID number on appropriate line. Other provider IDs can be entered on appropriate lines if desired. Medicaid

Form Locator

Required Field?

58 a, b & c

Required

59a, b & c

Optional

60a, b & c

Required

61a, b & c

Optional

62a, b & c

Optional

63a, b & c

Situational

Description and Instructions Insured’s Name: Enter the insured’s name on the applicable payer line. For Medicaid, the insured’s name is always the name of the patient, even in cases of organ or other tissue donors for a Medicaid insured patient. Patient’s Relationship to Insured: This is a 2 digit code. Enter code applicable to the payer line. For Medicaid patients, the relationship is always “self”. Insured’s Unique ID: Enter the appropriate insured’s ID number applicable to the payer line. For example, if the payer on line A is Medicare, enter the insured’s Medicare ID. For the Medicaid payer line, the insured’s ID is always the patient’s Medicaid ID. The Medicaid ID can be 9, 10 or 14 digits, all numeric. Insured’s Group Name: This is the group or plan name through which the insurance is provided. Not applicable to Medicaid but helpful if a primary commercial payer (not Medicare) is involved. Insured’s Group Number: The identifier assigned to the group through which insurance is provided. Not applicable to Medicaid but helpful if a primary commercial payer (not Medicare) is involved. Treatment Authorization Codes: On the Medicaid payer line, enter the prior authorization number when applicable. Only one Medicaid prior authorization number can be entered on a claim.

64 a, b & c

65a, b & c

Not Required

Not Required

66

Required

67

Required

67A – 67Q 68

Situational N/A

Document Control Number: For Medicaid claims, enter the 17-digit Medicaid assigned TCN for a previous submitted claim, which was received by ACS within the initial filing limit, on the Medicaid payer line. Employer Name: Enter the name of the employer that supplies insured with health insurance on appropriate payer line. Not applicable to Medicaid claims. Diagnosis and Procedure Code Qualifier (ICD Version Indicator): Always a 9 unless (or until) the ICD version 10 is mandated. Principal Diagnosis Code: Enter principal diagnosis code in the white area of this field. This is an ICD-9-CM diagnosis code. Code is not required on nursing home claims Other Diagnosis Codes: Enter other diagnosis codes that apply. These are ICD-9-CM codes. This field is not used. Leave blank.

Form Locator

Required Field?

Description and Instructions

69

Situational

70a, b & c 71

Optional Optional

72a, b & c 73 74

Situational N/A Situational

74a – e

Situational

75 76

N/A Situational

77

Optional

78 & 79

Optional

80 81a-d

Optional Optional

Admitting Diagnosis Code: Enter for inpatient claims, Part A inpatient crossovers and nursing home claims. Use ICD-9-CM diagnosis code. Patient Reason for Visit: Enter ICD-9 CM diagnosis codes if desired. Prospective Payment System Code: Not required, but expected DRG code can be entered here for inpatient claims. External Cause of Injury (ECI) Code: Enter valid ICD-9-CM ECI code when applicable. Unassigned: Leave blank Principal Procedure Code and Date: Required on inpatient claims when at least one of the following revenue codes are present on the claim: 0360-0379; 0490-0499; and 0710-0719. Enter a valid ICD-9 surgical procedure code. Enter date in mmddccyy format. If a code is present, a date must be present. If a date is present, a code must be present. Date must be within claim’s from and through date of service. Other Procedure Codes and Dates: Enter procedures other than the principal procedure and enter the date of the procedure in these form locators. Codes must be valid ICD-9 procedures. Enter dates in mmddccyy format. If a code is present, a date must be present. If a date is present, a code must be present. Date must be within claim’s from and through date of service. Unassigned: leave blank Attending Provider Name and Identifier: Attending provider data is only required on inpatient hospital claims. Only the attending provider’s NPI is required. The taxonomy of the attending provider is not required. Enter the attending provider’s 10-digit NPI in the NPI field. Enter last name and first name in appropriate fields. Operating Physician’s Name and Identifier: Enter the primary surgeon’s 10-digit NPI in NPI field. Taxonomy is NOT required, even if NPI is entered. Enter primary surgeon’s last name and first name in appropriate fields. Other Physician’s Name and Identifier: Enter other physicians’ 10-digit NPIs in the NPI field. Taxonomy is NOT required even if NPI is entered. Enter other physicians’ last names and first names in appropriate fields. Remarks: NM Medicaid does not use information entered in this field “Code-Code Field”: Form locator 81a is where the billing provider’s taxonomy code is entered. Taxonomy is not required but it is recommended. Enter “B3”, the taxonomy qualifier code, in the smaller box on the left and enter the billing provider’s 10-digit taxonomy code in the field immediately following the qualifier field.