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

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