UB 04 - Complete instruction to fill the form

Claim Specifications

Completing the UB-04 Form

Use the UB-04 form to complete a Medicare claim for institutional services. To complete this form, refer to the instructions in UB-04 Claim Form Specifications in this chapter. Field information is required unless otherwise noted. This form may be prepared according to Medicare guidelines as long as all required fields are completed.

UB-04 Paper Claim Submissions 

The Plan accepts UB-04 forms printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the form can be downloaded from the CMS website, copies of the form cannot be used for submission of claims and will be rejected since your copy may not accurately replicate the scale or color of the form when scanned using Optical Character Recognition (OCR).
This scanning technology allows for the data contained on the form to be read while the actual form fields, headings and lines remain invisible to the scanner. Photocopies cannot be scanned and therefore are not accepted.

There are key fields to properly identify and adjudicate claim information on a paper UB-04 form when submitted to our Plan. Below are guidelines identifying these fields to ensure timely and accurate processing of your claim submission.

UB-04 Guidelines for Paper Claims

* Block 56: Billing provider’s NPI number is entered here.

* Block 71 PPS Code: Enter DRG code, if applicable.

* Blocks 76-79 NPI: Include the attending, operating or other physician’s NPI number.

* Block 81CC: Enter the taxonomy codes corresponding to providers listed in fields 76-79.

Box Field Name Instructions

Enter the name and payment address of the hospital/provider.

Enter the address of the payee if different from the address in Box #1.

3 a-b
Patient Control Number
** 3a: Enter the patient account number as assigned by the hospital.
** 3b: Enter the medical record number

Type of Bill
Enter the 3-digit code to indicate the type of bill submitted.

Federal Tax Number
Enter the hospital/provider’s federal tax ID number.

Statement Covers Period
** Enter the beginning and ending services dates for the period covered by this bill (MMDDYY). These dates are necessary on all claims. For services received on a single day, both the FROM and THROUGH dates will be the same.
** If the FROM and THROUGH dates differ, Tufts Health Plan SCO requires these services to be itemized by date of service (refer to Box #45).

Not applicable.

8 a-b
Patient Name

** 8a: Enter patient ID number.

** 8b: Enter the patient’s last name, first name and middle initial, if any, as shown on the patient’s Tufts Health Plan SCO identification card.

9 a-e
Patient Address
Enter the patient’s mailing address from the patient record.

Enter the patient’s date of birth (MMDDYY).

Enter M or F.

Admission Date
Enter the date of this admission/visit.

Admission Hour (HR)
Enter the time of this admission/visit.

Admission Type
Enter the code indicating the type of this admission/visit.

Admission Source (SRC)
Enter the code indicating the source of this admission/visit.

Discharge Hour (DHR)
Enter the time the patient was discharged.

Patient Discharge Status (STAT)
Enter the code to indicate the status of the patient as of the THROUGH date on this billing (Box #6).

Condition Codes
Enter the code used to identify conditions relating to this bill that can affect payer processing.

Accident (ACDT) State
Enter the state in which an auto accident occurred, if applicable.

Not applicable.

Occurrence Codes and Dates
Enter the code and associated date defining a significant event relating to this bill that may affect payer processing.
Note: Tufts Health Plan requires reporting of all accident-related occurrence codes.

Occurrence Span: Codes and Dates
Enter a code and the associated dates that identify an event that relates to the payment of the claim.

Not applicable.

Not applicable.

Value Codes and Amounts
Not applicable.

Revenue (REV) Codes
Enter the most current uniform billing revenue codes.

Revenue Description
** Enter a narrative description of the services/procedures rendered.
** Whenever possible, use CPT-4/HCPCS definitions.

** For outpatient services, use CPT and HCPCS Level II codes for procedures, services and supplies.
** Do not use unlisted codes. If an unlisted code is used, then supporting documentation must accompany the claim.
** Do not indicate rates.

Service Date
Enter the date the indicated service was provided.

Units of Service
Enter the units of service rendered per procedure.

Total Charges
Enter the charge amount for each reported line item.

Non-Covered Charges
Enter any non-covered charges for the primary payer pertaining to the revenue code.

Not applicable.

50 A-C
Payer Name
** List all other health insurance carriers on file.
** If applicable, attach an EOB from other carriers.

Health Plan ID
List the provider number assigned by the health insurer carrier.

Release of Information (REL INFO)
Not applicable.

Assignment of Benefits (ASG BEN)
Not applicable.

Prior Payments (payer and patient)
** Report all prior payment for the claim.
** Attach EOB from another carrier, if applicable.

Est. Amount Due
Not applicable.

Enter valid NPI number of the servicing provider.

57 A-C
Other Provider (PRV) ID
Not applicable.

58 A-C
Insured’s Name
Enter the name of the individual carrying the insurance.

59 A-C
Patient’s Relationship to the Insured (P REL)
Enter the code indicating the relationship of the patient to the identified insured/subscriber.

60 A-C
Insured’s Unique ID
Enter the patient’s Tufts Health Plan Senior Care Options identification number, including the suffix, as shown on the patient’s Tufts Health Plan Senior Care Options member identification card.

61 A-C
Group Name
Enter the name of the group or plan through which the insurance is provided to the insured.

Insurance Group Number
Enter the identification number, control number, or code assigned by the carrier or administrator to identify the group under which the individual is covered.

63 A-C
Treatment Authorization Code
Enter the Tufts Health Plan Senior Care Options authorization number

Document Control Number
Not applicable.

Employer Name
Enter the name of the employer for the individual identified in Box #58, if applicable.

DX Version Qualifier
Not applicable.

67 a-q
Principal Diagnosis Code
** Enter the most current ICD-CM code describing the principal diagnosis chiefly responsible for causing this admission/visit. The code must be to the appropriate digit specification, if applicable.
** If the diagnosis is accident-related, then an occurrence code and accident date are required.
** The POA indicator is the 8th digit of the Field Locator and the 8th digit of each of the Secondary Diagnosis fields, a-q. Report the applicable POA indicator (Y, N, U, or W) for the principal and any secondary diagnoses and include this as the 8th digit.
** Leave this field blank if the diagnosis is exempt from POA reporting.

Other Diagnosis Codes
** Enter the ICD-CM-CM diagnosis codes corresponding to additional conditions that co-exist at the time of admission or develop subsequently.
** If applicable, the code must be to the appropriate digit specification.

Admit DX
Enter the ICD-CM-CM diagnosis code provided at the time of admission and as stated by the physician.

Patient Reason DX

PPS (Prospective Payment System) Code

ECI (External Cause of Injury) Code
Enter the ICD-CM-CM code for the external cause of an injury, poisoning, or adverse effect.

Not applicable.

74 a-e
Principal Procedure Code (code and date)
** Enter the most current ICD-CM code to the appropriate digit specification, if applicable, to describe the principal procedure performed for the service billed.
** Also enter the date the procedure was performed. The date must be entered as month and day (MMDD).

Not applicable.

Attending Physician
Enter the ordering physician’s NPI, physician’s last name, first name and middle initial.

Enter the name and NPI number of the physician who performed the principal procedure, if applicable.

Other Provider Types

Not applicable.

81 a-d

Required Information for Submission of Hospital/Facility Claims

Required Information Description

Billing FTIN Federal tax identification number of the organization requesting reimbursement

Facility ID/NPI Number UnitedHealthcare Oxford-assigned provider identification number and NPI number of the facility
requesting claim reimbursement, e.g., HO1234, ANC123 Billing Facility Name Name of the organization requesting claim reimbursement Billing Facility City, State, Zip

Code City, state and zip code of organization requesting claim reimbursement Billing Address Street address of the organization requesting claim reimbursement Patient UnitedHealthcare Oxford ID number

UnitedHealthcare Oxford member identification number of person to whom services are being rendered (Do not use a space or an asterisk when entering the Member ID number, e.g., 17935801)

Patient Last Name Last name of the patient

Patient First Name First name of the patient

Patient Gender Sex of the patient

Patient Date of Birth Date of birth of the patient (Eight spaces are provided for the date of birth, e.g., 01011957 not 010157)

Revenue Code(s) Code that identifies a specific accommodation, ancillary service or billing calculation Diagnosis Code(s) The ICD-CM code describing the principal diagnosis (i.e., the condition determined after study to be chiefly responsible for admitting the patient for care) Date(s) of Service Date(s) on which service was performed (“From-To” dates are accepted for inpatient charges only; outpatient charges must be entered line-by-line for each date-of-service)

Place Code(s) or Place of Service

Code(s) used to indicate the place where procedure was performed Requested Amounts Total billing amount requested by the provider Required Information Description

CPT/HCPC Code(s) The charge or fee for the service itemized by each HCPC or CPT-4 code, (i.e., per service or procedure; inpatient charges do not require CPT codes; outpatient charges require CPT codes) Units of Service As appropriate - A quantitative measure of services rendered by revenue category to or for the pints of blood, renal patient to include items such as number of accommodation days, miles, pints of blood, renal dialysis treatments, etc.

Condition Code(s) As appropriate - Code(s) used to identify relating conditions that may affect claim processing

Occurrence Code(s) As appropriate - Hospital/Facility codes and associated dates defining a significant event relating to this bill that may affect claim processing

Occurrence Span Code(s) As appropriate - Hospital/Facility codes and the related dates that identify an event that relates to the payment of the claim

Assignment of Benefits As appropriate - Authorization for claim reimbursement to be made to billing provider Coordination of Benefits As appropriate - Coverage in addition to UnitedHealthcare Oxford Statement Covers Date The beginning and ending service dates of the period included on this claim Covered Days The number of days covered by the primary insurer, as qualified by that organization Non-covered Days Days of care not covered by the primary insurer Coinsurance Days The inpatient Medicare days occurring after the 60th day and before the 91st day, or inpatient skilled nursing facility swing bed days occurring after the 20th and before the 101st day in a single period of illness

Lifetime Reserve Days Under Medicare, each beneficiary has a lifetime reserve of 60 of additional days of inpatient hospital services after using 90 days of inpatient hospital services during a period of illness

Patient Marital Status The marital status of the patient at date of admission, outpatient service or start of care Admission/Start of Care Date The date the patient was admitted to the provider of inpatient care, outpatient service
or start of care

Admission Hour The hour during which the patient was admitted for inpatient or outpatient care

Admission Type Hospital/Facility code indicating the priority of this admission

Admission Source Hospital/Facility code indicating the source of this admission

Discharge Hour Hour that the patient was discharged from inpatient care Patient (discharge) Status Hospital/Facility code indicating patient status as of the ending service date of the period covered on this bill, as reported in field 6 of the form Medical/Health Record Number The number assigned to the patient’s medical/health record by the provider Treatment Authorization Codes A number, Hospital/Facility code, or other indicator that designates that the treatment covered by this bill has been authorized by UnitedHealthcare Oxford Admitting Diagnosis Code The ICD-9-CM or ICD-10 diagnosis code (effective for DOS 10/1/15 and after) provided at the time of admission, as stated by the physician External Cause of Injury Code The ICD-9-CM or ICD-10 code (effective for DOS 10/1/15 and after) for the externalcause of an injury, poisoning or (E-code) adverse effect

Hospital Claims Filing Instructions - Outpatient

Following current standardized billing requirements for outpatient hospital services, CPT®  and HCPCS codes will be required when the revenue codes listed below are used.

Code Description
0261 IV Therapy; Infusion Pump
0274 Med/Surg Supplies - Prosthetic/Orthotic Devices
030X Laboratory - Clinical Diagnostic
031X Laboratory - Pathology
032X Radiology - Diagnostic
033X Radiology – Therapeutic
034X Nuclear Medicine
035X CT Scan
036X Operating Room Services
038X Blood: Packed Red Cells
0391 Blood Storage/Processing: Blood Administration
040X Other Imaging Services
041X Respiratory Services
042X Physical Therapy
043X Occupational Therapy
044X Speech Language Pathology
045X Emergency Room
046X Pulmonary Function
047X Audiology
048X Cardiology
049X Ambulatory Surgery
051X Clinic
052X Free Standing Clinic
053X Osteopathic Services
054X Ambulance
0561 Medical Social Services: Visit Charge
0562 Medical Social Services: Hourly Charge
057X Visit Charge
059X Home Health – Units of Service
060X Home Health – Oxygen
061X Magnetic Resonance Tech (MRI)
0623 Surgical Dressings
0634 Drugs Require Specific ID: EPO under 10,000 Units
0635 Drugs Require Specific ID: EPO over 10,000 Units
0636 Drugs Require Specific ID: Drugs Requiring Detail Coding
064X Home IV Therapy Services
065X Hospice Service
067X Outpatient Special Residence Charges
0722 Labor Room: Delivery
0723 Labor Room: Circumcision
0724 Labor Room: Birthing Center
074X EEG
075X Gastrointestinal Services
0760 Treatment/Observation Room
0761 Treatment/Observation Room: Treatment Room
0769 Treatment/Observation Room: Other Treatment Room
077X Preventative Care Services
078X Telemedicine
079X Extra-Corp Shock Wave Therapy
0811 Organ Acquisition: Living Donor
0812 Organ Acquisition: Cadaver Donor
0813 Organ Acquisition: Unknown Donor
0814 Organ Acquisition: Unsuccessful Organ Search Donor Bank Charges
083X Peritoneal OPD/Home
084X CAPD OPD/Home
085X CCPD OPD/Home
088X Miscellaneous Dialysis
090X Psychiatric/Psychological Treatment
091X Psychiatric/Psychological Services
092X Other Diagnostic Services
0940 Other Therapeutic Services
0941 Other Therapeutic Services; Recreation RX
0943 Other Therapeutic Serv: Cardiac Rehab
0944 Other Therapeutic Serv: Drug Rehab
0945 Other Therapeutic Serv: Alcohol Rehab
0946 Complex Medical Equipment - Routine

The National Uniform Billing Committee (NUBC) UB-04 claim form must be used when submitting paper claims. It must be a red-ink form with UB-04 CMS-1450 in the lower left corner. Use of forms other than the red ink version will result in errors when they are scanned by the Optical Character Reader (OCR).

Providers are encouraged to bill electronically whenever possible.

Claims may be prepared on a typewriter or on a computer. Handwritten claims are not accepted.

Because claims are optically scanned prior to processing, print or alignment problems may cause misreads, thus delaying processing of the claim. Keep equipment properly maintained to avoid the following:

** Dirty print elements with filled character loops.

** Light print or print of different density.

** Breaks or gaps in characters.

** Ink blotches or smears in print.

** Worn out ribbons.

Questions and problems with the compatibility of equipment with MDHHS scanners should be directed to MDHHS Provider Inquiry. (Refer to the Directory Appendix for contact information.)

Paper claims should appear on a remittance advice (RA) within 60 days of submission. Do not resubmit a claim prior to the 60-day period.


To ensure that the scanner correctly reads claim information, adhere to the following guidelines in preparing paper claims. Failure to adhere to these guidelines may result in processing/payment delays or claims being returned unprocessed.

** Date of birth must be eight digits without dashes or slashes in the format MMDDCCYY

(e.g., 03212002). All other dates must be six digits in the format MMDDYY. Be sure the dates are within the appropriate boxes on the form.

** Use only black ink.

** Do not write or print on the claim, except for the Provider Signature Certification.

** Handwritten claims are not acceptable.

** UPPER CASE alphabetic characters are recommended.

** Do not use italic, script, orator, or proportional fonts.

** 12-point type is preferred.

** Make sure the type is even (on the same horizontal plane) and within the boxes.

** Do not use punctuation marks (e.g., commas or periods).

** Do not use special characters (e.g., dollar signs, decimals, or dashes).

** Only service line data can be on a claim line. Do not squeeze comments below the service line.

** Do not send damaged claims that are torn, glued, taped, stapled, or folded. Prepare another claim.

** Do not use correction fluid or correction tape, including self-correction typewriters.

** If a mistake is made, the provider should start over and prepare a clean claim form.

** Do not submit photocopies.

** Claim forms must be mailed flat, with no folding, in 9" x 12" or larger envelopes.

** Put a return address on the envelope.

** Separate the claim form from the carbon.

** Separate each claim form if using the continuous forms and remove all pin drive paper completely. Do not cut edges of forms.

** Keep the file copy.

** Mail NUBC claim forms separate from any other type of form.


When a claim attachment(s) is required, it must be directly behind the claim it supports and be identified on each page with the beneficiary’s name and Medicaid ID number. Attachments must be on 8 ½" x 11" white paper and one-sided. Do not submit twosided material. Multiple claims cannot be submitted with one attachment. Each claim form that requires an attachment must have a separate attachment. Do not staple or paperclip the documentation to the claim form.

Mail claim forms with attachments flat, with no folding, in a 9" x 12" or larger envelope and print "Ext. material" (for extraneous material) on the outside. Do not put claims that have no attachments in this envelope. Mail claims without attachments separately. Do not send attachments unless the attachment is required as unnecessary attachments delay claim processing.

Claim attachments, such as medical records and EOBs, may be associated to a paper claim via the Document Management Portal. (Refer to the Directory Appendix for website information.)

Once confirmation is received that the consent forms are approved, it is not necessary to submit additional copies when billing for sterilization or hysterectomy services. The notation "Consent form sent via Document Management Portal" must be included in the Remarks section of the paper claim.

Claims – UB 04 - Medicaid instrutcion


• Encourage the pregnant patient to select a PMP for her child prior to its birth.

• Pre-selection Form will soon be available on our website. A copy is in your packet.

• All newborns must be billed under their own Medicaid ID number.

DO NOT bill under the mother’s Medicaid ID number

• It could be 30 days before our system will receive the newborn’s Medicaid ID number in our system. We have instituted a process to allow for billing when you have the Newborn’s Medicaid ID number before we receive it in our membership file.

Step 1:
• Fill out the Newborn Notification Enrollment Report. See www.anthem.com for the form.

• Email materials to membershipD950@wellpoint.com of fax materials to 877-833-5735.

Step 2:
• File your claims electronically after the 3rd business day from the date you submitted the Newborn Notification Enrollment Report. Daily cutoff is 3:00 pm. Eastern (Indianapolis time) Outpatient Surgery and Ambulatory Surgery Centers (ASC)

• Reimbursement is all-inclusive flat fee

• Lump all charges and services with surgical procedure

Outpatient Surgery and ASC, continued
• Multiple Surgeries

• Maximum of two reimbursed, regardless of number of incisions.

• Same incision – only reimburse the one with the highest ASC rate.

• Separate incision – only reimburse the one with highest ASC rate.

• Primary surgery reimbursed at 100%.

• One separate incision / secondary surgery reimbursed at 50%.

• Bilateral procedures are reimbursed at 150%.

• List appropriate revenue code and CPT code as two separate detail line items.

• Emergency Transportation:

• All emergency transportation should be billed to Anthem Hoosier Healthwise using the CMS 1500.

• Emergency Transportation is any transportation requiring Advanced or Basic Life Support.

• A0425 – Ground Mileage, per statute mile.

• Modifiers include: U1, U2, U3, U4, and U5.

• Non emergent transportation:

• Should be arranged through LCP Transportation at 800-508-7230

• 48 hours notice for non emergent appointments

• 24 hours or less notice may be given in a case of sickness with a physician appointment scheduled that day.

• Non emergent transportation is unlimited.

• Hospital outpatient – bill on UB92/CMS1450/UB 04

• Physicians and Independent Labs – bill on CMS 1500.

Coordination of Benefits (COB)

• When submitting COB claims, specify the other coverage and payment information in the appropriate Form Locator – 50A-55C of the UB 04 form.

• We must receive COB claims within 180 days from the date on the other carrier’s or program’s RA, or letter denial of coverage.

• COB claims must be submitted on paper. Do not file electronically.

• Include the member’s Medicaid number, including the YRH prefix along with the member’s Medicaid #.

• Attach the third party Remittance Advice or letter explaining the denial with the CMS claim form.

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