The UB-04 Claim Form

1. PART TWO The UB-04 Claim Form Chapter 6 Overview of the UB-04 Claim Form

2. LEARNING OUTCOMES After completing this chapter, you will be able to define the key terms and: Discuss the history of the UB-04 claim form in the medical health billing environment. Discuss UB-04 claim creation and methods of transmittal to payers. Describe the importance of preparing clean claims. Describe the data elements and the general formats that are used for the form locators on the UB-04. Explain the purpose of the seven form locators designated as unlabeled fields on the UB-04. Explain the organization of the remaining chapters in Part 2 of this text.

3. KEY TERMS • claim denial • claim rejection • clean claim • CMS-1500 • CMS-1450 • delimiter • detail-level code • 837I • 837P • form locator (FL) • HIPAA claim • paper claim • UB-04

4. EVOLUTION OF THE UNIFORM BILL • 1982: first attempt by the National Uniform Billing Committee (NUBC) to develop single claim form with standard data set for institutional health care claims nationwide = UB-82 • 1992: improved design and data set; used for inpatient and outpatient claims; used for expanded types of facilities = UB-92 • 2003: HIPAA/837I claim introduced as electronic counterpart to UB-92 • 2004: paper form updated to be more consistent with 837I = UB-04 (effective 3/1/2007) • Most information on UB-04 and 837I is the same; some instances where data requirements or format differ

5. USE OF THE UB-04 CLAIM FORM • UB-04 or 837I (electronic counterpart) is only claim form accepted by Medicare for Part A reimbursement • Used by most other payers including other government programs • Used for all hospital charges except physician charges • Physician charges (referred to as the professional component) are billed on the CMS-1500 form or 837P electronic transaction

6. CLAIM CREATION AND TRANSMISSION • 837I is created and transmitted without the use of paper; it is an electronic data interchange (EDI) transaction that sends information from the hospital’s computer system directly to the computer of the payer or a clearinghouse (formats the information and transmits it to the payer) • Advantages of electronic claim transmission over paper claims: • more efficient and less expensive • fewer errors and omissions (data entered only once and not re-entered on the receiving end) • EDI claims reimbursed faster by Medicare

7. Clean Claims • Clean claim = claim that meets all necessary specifications and passes all predetermined data edits • Medicare billing rules call for payment or denial of clean claims by the thirtieth day after receipt; otherwise, Medicare must pay interest • Claims that do not meet necessary specifications: • claim denial: whole claim has been denied; provider cannot resubmit, but can appeal the denial • claim rejection: whole claim has been rejected; provider can correct and resubmit the claim, but cannot appeal it • Keeping Up with Changes • CMS and NUBC make regular changes to the data fields and codes used in the UB-04 • Many sources of information on these changes can be located through the CMS website and Online Manual System

8. FORM LOCATORS • A form locator (FL) is a numeric indicator for a specific box on a data collection form. • The UB-04 has 81 data elements in 81 form locators. • Billing rules for each FL specify: • type of data that must be entered in the field • format of the data (e.g., numeric, alphanumeric) • number of characters (letters, numbers, etc.) allowed

9. UB-04 Front

10. UB-04 Back

11. Form Locator Groupings • Form locators are grouped in 10 sections, each containing a similar type of data: • FLs 1-7 Provider information • FLs 8-17 Patient information • FLs 18-30 Condition codes • FLs 31-38 Occurrence codes and dates • FLs 39-41 Value codes and amounts • FLs 42-49 Revenue codes, descriptions, and charges • FLs 50-65 Payer, insured, and employer information • FLs 66-75 Diagnosis and procedure codes • FLs 76-79 Physician information • FLs 80-81 Remarks and Code-Code field

12. Required Formats • Each Form Locator has a required format: numeric, alphabetic, alphanumeric, or text-based • Some FLs contain a formatting element called a delimiter which is a character or symbol that visually separates one group of words or values from another and makes them easier to read (e.g., the vertical column of dots that separates dollars and cents) • Unlabeled Form Locators • Eleven FLs are unlabeled: 7 are reserved for future use; 4 are assigned fields for provider use • FL 1: Provider Name, Address, and Telephone Number • FL 2: Pay-to Name and Address • FL 38: Responsible Party Name and Address • FL 67: Principal Diagnosis Code and Present on Admission Indicator

13. CHAPTER ORGANIZATION AND COVERAGE IN PART 2 • Each of the 9 subsequent chapters in Part 2 provides details for a group of form locators on the UB-04 • Main focus of the text is correct processing of inpatient and outpatient hospital Medicare claims

14. CHAPTER REVIEW • List two advantages of using EDI transmittals instead of paper claims: • [more efficient and less expensive][less chance of errors and omissions][faster reimbursement by Medicare] • List three of the most common problems that prevent a claim from passing the clean claim requirements: • [incorrect patient ID number][patient name and address do not match payer’s records][insufficient or no information about insurance coverage][incorrect dates of service][dates that lack the correct number of digits][revenue codes not listed in ascending order][missing data][fee column blank or not itemized and totaled][invalid CPT or ICD-9-CM codes, or diagnosis codes that are not linked to correct services or procedures]

15. CHAPTER REVIEW (cont.) • Can a claim denial be corrected and resubmitted? • [no, only appealed ] • What is the name of the committee that developed the UB-04? • [National Uniform Billing Committee] • What is the purpose of an unlabeled form locator? • [reserved for future use] • This text focuses on processing what kind of claims? • [inpatient and outpatient hospital Medicare claims]

16. TERMINOLOGY QUIZ • UB is an abbreviation for: • [Uniform Bill] • The electronic transaction for physician claims is 837P. What does the P stand for? • [Professional] • A claim that can be corrected and resubmitted, but not appealed. • [rejected claim] • The electronic transaction for hospital claims is 837I. What does the I stand for? • [Institutional]

17. TERMINOLOGY QUIZ (cont.) • EDI is the abbreviation for: • [electronic data interchange] • A claim that can be appealed, but not corrected and resubmitted: • [denied claim] • Character or symbol used to visually separate one group of words or values from another: • [delimiter]