UB-04 Claim Form | PDF
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The UB-04 claim form may be used by institutional healthcare providers for submitting insurance claims. Also known as the CMS-1450 form, this is the industry standard for paper billing of all insurance carriers.
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How to Fill-in
The form has numbered entries called “form locators” that require specific information necessary to process an insurance claim. Filling out the form properly and accurately is important because the insurance company could reject a claim if the form is inaccurate. Some insurance companies do not require you to fill out each entry space, so check with your insurance provider to be sure how to accurately fill out your form.
As some of the fields on the form are not self-explanatory, here are tips for completing many of them:
- 3a – Patient Control Number: Place the patient’s healthcare provider account number here (the number used to retrieve account information).
- 5 – Federal Tax Number: Enter the healthcare provider’s federal tax number here.
- 8a – Patient Name Identifier: This is a number from the patient’s ID, which you only need to enter if it’s different from the insured’s ID number. Section 8b is for the patient’s actual name.
- 13 – Time of Admittance: Enter the hour of admittance using military time. Use military time for section 16 as well.
- 18 through 28 – Condition Codes: These fields are where you enter codes for conditions that may affect bill processing.
- 39 through 41 – Value Codes and Amounts: Here you enter codes and corresponding dollar amounts so insurance providers understand the costs of the claims.
- 42 – Revenue Code: Here, you enter the HIPAA complaint numeric code corresponding to a description that identifies a specific accommodation or service.
- 43 – Revenue Description: The description that corresponds to the revenue code from section 42.
- 44 – HCPCS / Rate / HIPPS Code: This field is used to report the HCPCS codes for ancillary services, the rate for inpatient bills, and “the Health Insurance Prospective Payment System rate codes for specific patient groups that are the basis for payment under a prospective payment system.”
- 46 – Service Units: Here you report how many pints of blood were used in the services, miles travelled, or number of inpatient days.
- 47 and 48: Section 47 includes charges that are and are not covered, whereas section 48 just asks for covered charges.
- 50 – Payer Name: Complete this section if secondary or tertiary payers will pay for part of the claim.
- 53 – Assignment of Benefits Indicator: Fill this out if the provider has a signed form authorizing a third-party insurer to pay the provider directly.
- 58 – Insured’s Name: Must match name on the insured person’s insurance ID card.
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