Following these samples are instructions for completing each field on the ub 04 claim form. Refer to the national uniform claim committee nubc instruction manual available at. This fourdigit alphanumeric code gives three specific pieces of information after a leading zero. Bcbsma supplement to the nubc ub 04 data specifications manual our guide provides specific instructions to help you complete the ub 04 paper. The ub04 manual national uniform billing data element specifications as developed by the national uniform billing committee current revision should be used in conjunction with this provider billing guideline as a reference guide for. Specifications manual for joint commission national quality measures v2011a discharges 040111 2q11 through 123111 4q11.
In 1982, the nubc voted to healthcare accept the 82 and its associated data manual for implementation as a national uniform bill. Numerous and significant changes have been made to the ub04 manual from 2011 through 2017. Up to four 4 15 minute units can be billed per service date. It has been created as an adobe portable document file pdf that allows users to print or view the file from their computer. The ub04 data specifications manual contains a blank facsimile of the in certain assumptions by the department and will preclude corrections of. The national uniform billing committee nubc makes their ub04 manual as situational in an implementation guide and are accessed by visiting the. The electronic medicaid provider manual contains coverage, billing, and reimbursement policies for medicaid, healthy michigan plan, childrens special health care services, maternity outpatient medical services moms, and other healthcare programs administered by the michigan department of health and human services mdhhs. Nubc occurrence codes february 20, 2020 admin no comments. Bcbsma supplement to the nubc ub04 data specifications manual our guide provides specific instructions to help you complete the ub04 paper. Appendixftjc manual performance measurement network. The revision date and transmittal number apply only to red italicized. You can access the ub04 billing information adopted by the nubc by subscribing. Submitting paper claim bcbs cms 1500 claim form and ub 04. Aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare pdf download medicare benefits pdf download.
The displayed claim form is a sample and is for illustration. Chars 837i 5040 companion guide department of health. Tennessee department of health office of healthcare statistics. Although the instructions that follow are based on the ub04 paper claim form, they are also intended as a guideline for. A sample of the back of the form is shown on the next page. Hmsa has determined that it will use the national uniform billing committee nubc official ub04 data specifications manual as the standard source for codes and code descriptions to be entered in the various form locators fl. Ub04 user guide blue cross blue shield of new mexico. These data elements are published in the national uniform billing data element specifications manual, which contains instructions for completing the ub 04 claim form.
The provider enters the code indicating the source of the referral. All code values listed in the nubc ub04 reference manual for each form locator ub04 claim form medical. Offline and online access to the 2012 ub04 manual expires 63012. To obtain complete code information, visit or visit their website. Effective august 1, 2011, the nubc has updated instructions for reporting units that now allows for fractional unit billing, therefore, cms is now providing notice that the exception to bill whole units on. Admission type code 9 and admission source code 9 are not allowed. Please refer to the manual for detailed\ answers to. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual.
Oregon medical fee and payment rules oregon administrative. For information on the ub04 billing form, or to obtain an official ub04 data specifications manual, visit the national uniform billing committee nubc web. Apr 28, 2011 determine the data elements and design of the ub 04. Kaiser permanente will continue to accept ub92 form based on cms guidelines. Point of origin codes update to the ub 04 cms1450 manual code list national uniform billing committee nubc, will be accepted into the fiscal. National uniform billing committee 6 excerpt from medicare publication ub04 overview background the national uniform billing committee nubc is responsible for the design and printing of the ub04 form.
A sample of the front of the ub 04 claim form is shown below. Billing and payment topic explanation instructions paper claims, cont. National uniform billing committee american hospital association one north franklin, 29th floor, chicago, il 60606. Finance medicare nubc manual for specific codes illinois. Type of bill 1st position 3rd postion medical billing. Apr 1, 2004 cms1450, is being updated to include new condition and value codes approved by the. New york state electronic medicaid system ub04 billing guidelines version 2011 01 23 2011. The following changes have been made by the national uniform billing committee nubc and are outlined below. The subscription period runs from july 1, 2011 through june 30, 2012. No other publication governmental or privatecommercial can be considered authoritative.
National uniform billing committee nubc and to ub04 billing guide inpatient hospitals 02017. Hospital discharge data system user manual august 2018 7 numerous and significant changes have been made to the ub04 manual from 2011 through 2018. Instructions for completing the ub04 claim form san francisco. To become a ub04 subscriber, refer to the national uniform billing committee nubc web site.
New york state electronic medicaid system ub04 billing. Official ub 04 data specifications manual 2020 by american hospital association. The ub04 manual national uniform billing data element specifications as developed by the nubc current revision should be used in. Origin for admission or visit codes to the ub04 cms1450 manual code list. Form locator 4 type of bill frequency code excerpts for 837p and 837d. National uniform billing committee nubc update to chapter 25. Dec 4, 2018 identify the section in the provider manual related to ub04 claim form completion icd10cm diagnosis codes and icd10 pcs codes on a claim to ensure payment at the nubc ub04 data specifications manual. Guide to the ub04 manual this ub04 manual is the official source for ub04 information adopted by the nubc. Some fields have been have been changed or codes have been added or deleted for existing fields. A sample of the front of the ub04 claim form is shown below. Cms 1500 claim form and ub 04 form instruction and guide. However, in some cases, hmsa varies from nubc directions concerning whether a specific field is required or how the.
Everyone is on the same subscription cycle of 71to 630. Nubc together to develop a single billing form and standard dataset that could be used nationwide by institutional providers and payers for handling claims. American medical association 515 north state street, chicago, il 60610 phone 8006218335 to order the nubc ub04 data specifications manual, contact. This manual, ed by the american hospital association, is the only. Sep, 2017 admission or visit codes to the ub04 cms1450 manual code list. Data collection in the ub04 format began may 2007 with the file format also switching to the 837i 4010 standard. The official ub04 data specifications manual 2020 is the source of ub04 billing information adopted by the national uniform billing committee nubc. Apr 06, 2011 determine the data elements and design of the ub 04. Jan 30, 2017 inpatient hospitals provider type 01 and specialty 010 for larc long. If you would like to enroll in the ub 04 subscription service to receive a complete ub 04 manual and updates, visit. This manual, available by annual subscription license, contains the updated specifications for the data elements codes included on the ub04 uniform bill claim form. Ub virtually all states adopted the use of the ub82. Type of bill 1st position 3rd postion place of service crosswalk type of bill located on the national uniform billing committee nubc approved ub04 claim form, also known as cms1450, in field 4. Masshealth billing guide for the ub04 executive office of.
Per the national uniform billing committee nubc, the priority type. Following this sample are instructions for completing each field on the ub04 claim form. Dec 4, 2018 identify the section in the provider manual related to ub 04 claim form completion icd10cm diagnosis codes and icd10 pcs codes on a claim to ensure payment at the nubc ub 04 data specifications manual. To get a copy, contact the nubc, american hospital association, 155 north wacker drive, suite 400, chicago, il 60606, 3124223000, or. The national uniform billing committee nubc has approved the new ub04 cms1450 as the replacement for the ub92. However, in some cases, hmsa varies from nubc directions concerning whether a specific field is required or how the data is to be entered in a specific field. In 2011 12 chars transitioned to the 837 5010 file format and october 1, 2014 with the united states will move to icd10 codes. These data elements are published in the national uniform billing data element specifications manual, which contains instructions for completing the ub04 claim form. Cmcm providers who choose to submit their claims on paper forms must use the national uniform billing committee nubc ub04 claim form. Kaiser permanente provider manual 831 2011 4 section 5. If you would like to enroll in the ub04 subscription service to receive a complete ub04 manual and updates, visit. The chars procedure manual and chars companion guide supplement the national uniform billing committee uniform billing form 2004 nubc ub04 and the asc x12. The nubc is a voluntary, multidisciplinary committee that.
Aarp health insurance plans pdf download medicare replacement pdf download medicare benefits pdf download. The nubc official ub04 data specifications manual includes a number of questions and answers related to the appropriate use of these codes. Dec 11, 2019 apr 1, 2004 national uniform billing committee nubc and to add all nubc additionally, all codes that have been approved by the nubc and that se1117 cms. Each client is allowed a maximum of 260 units which can be billed over a two and a half year time period. Point of origin codes update to the ub04 cms1450 manual code list national uniform billing committee nubc, will be accepted into the fiscal. Kaiser will begin accepting the new ub04 on march 1, 2007.
Some fields have been have been changed or codes have been added or. To order the cpt 2011 or the cpt assistant, contact. Many types of providers use the ub04 claim form to bill. Submitting paper claim bcbs cms 1500 claim form and ub. To view a sample cmcm ub04 claim form, see appendix a. Aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare pdf download. All code values listed in the nubc ub 04 reference manual for each form locator ub 04 claim form medical.
This manual, ed by the american hospital association, is the only official source of ub data. Code of structure for newborn used for pc04 and pc05 only 14 reserved for assignment by the nubc. Hospitals and renal dialysis providers should use the billing guidelines in the handbook for hospitals services, appendix h2, in conjunction with the ub04 data specifications manual. Per the nubc, the point of origin for admission or visit code is required for all institutional claims except for bill type 014x. The national uniform billing committee nubc maintains the lists of approved codes for the form. Specifications manual for joint commission national quality measures v2011a discharges 04 0111 2q11 through 123111 4q11. Some fields have been changed, or codes have been added or deleted for existing fields. Dataelem0270 manual performance measurement network. The national uniform billing committee nubc has approved the new ub04 cms1450 as the replacement for ub92. Jun 25, 2011 type of bill 1st position 3rd postion place of service crosswalk type of bill located on the national uniform billing committee nubc approved ub04 claim form, also known as cms1450, in field 4. National uniform billing committee nubc, effective april 1, 2004, that specifies cms manual system. Ub04 data specifications manual and the centers for medicare and medicaid services.
Apr 1, 2004 national uniform billing committee nubc and to add all nubc additionally, all codes that have been approved by the nubc and that se1117 cms. The revision date and national uniform billing committee nubc designated the. The displayed claim form is a sample and is for illustration purposes only. Tips for completing the ub04 cms1450 claim form revised 04. Instructions for completing the ub 04 claim form the ub04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities for example, outpatient departments, rural health clinics, chronic dialysis and adult day health care. The official ub 04 data specifications manual, ed by the american hospital association, is the only official source of ub 04 billing information adopted by the national uniform billing committee nubc. The revision date and national uniform billing committee nubc designated the publication cpt 200x x to current. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. The ub04 manual national uniform billing data element specifications as developed by the national uniform billing committee current revision should be used in conjunction with this provider billing guideline as a reference guide for the preparation of claims to be submitted to nys medicaid. R2250cp 07012011 nonsystems internet only manual iom. National uniform billing committee nubc, will be accepted into the. Patient discharge status \2 positions, numeric\\r\rrequired\r\rnote. This form, also known as the ub04, is a uniform institutional provider bill suitable for. Please make sure all billing staffs are aware of these changes.
A ub04 with field descriptions and instructions is included in the link below. Jan 05, 2015 the national uniform billing committee nubc makes their ub04 manual as situational in an implementation guide and are accessed by visiting the. It is organized by the corresponding boxes or form locators on the paper ub04. Kaiser permanente provider manual revised 2011 9 section 5.