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D M 71 PPS E N ECI F O 76 ATTENDING G P NPI LAST c. d. e. 77 OPERATING 81CC UB-04 CMS-1450 APPROVED OMB NO. 0938-0997 NUBC National Uniform Billing Committee QUAL FIRST 80 REMARKS H Q THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. UB-04 NOTICE THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM MAY SERVE AS THE BASIS FOR CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON...

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The UB-04 Form Makes Claiming Payments Easier

There are two standard forms designed by the CMS (Centers for Medicare and Medicaid) for billing claims: CMS Form 1500 and CMS Form UB-04, also known as CMS-1450. Both are approved by the NUBC (National Uniform Billing Committee). Though these forms have similar purposes, they are used by different authorities, as explained in further detail below.

Who needs a Form UB-04?

UB-04 Form is used by institutional providers, like hospitals, rehabilitation facilities, home health agencies, therapy services, etc. All establishments that can be classified as medical institutions must bill medical claims by filing UB-04 (CMS-1450) Forms, which has become the standard form requested by insurance companies.

The CMS-1500 Form, in contrast, is filled out by non-institutional providers: physicians and suppliers, for instance, specialty care providers, ambulance services, or clinical laboratories.

What is the UB-04 for?

The UB-04 form serves as a bill which displays and summarizes the cost of all the medical services a patient is given at the time of their treatment. The information reported on the CMS-1450 form will be required by the patient when they apply for insurance coverage.

Is the UB-04 accompanied by other forms?

Form UB-04 is applied only to cases involving medical treatment. While hospital stays and medical treatments always generate additional documentation, including patient medical records, hospital discharge papers, etc., filing form UB-04 does not require the provision of any of these additional documents or statements.

When is the UB-04 due?

UB-04 Form does not have a period of validity. It should be filled out and delivered to the patient when payment for services is due. The complete package should be sent by the patient to the insurance company no later than 12 months from the date of treatment.

How do I fill out the UB-04?

There are 81 fields to be completed in the fillable Form UB-04. They may be grouped according to the topic of items covered:

Patient’s personal information (name, address, date of birth).
Information about admission to the medical institution.
Treatment and medical services (and their costs).
Insurance details, etc.

Where do I send the UB-04?

The completed form should be delivered to the patient, their insurance company or any other party willing to make payments for the patient.

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Instructions and Help about form ub04 printable and fillable

Hey everyone for this week's activity we're going to be completing the CMS 1500 and the UB for claims forms so you have the information that you need listed in the activities and there's also a document that I added under the handouts tab that has the patient data table in the provider data table located - in the handouts portal of unit 10 so I'm not going to completely fill out all of the information on the two forms that we're completing but I do at least want to get you started so if you take a look at the UB for one of our first examples is with Abby Addison so essentially all of the different data fields on the you before in the CMS 1500 have specific information entered into each of these you can find more information about what is entered into each and every field in these step-by-step directions for completing there's tips for completing the CMS 1500 form and also completing the ubo for claims form found under handouts as well so back to the ubo for I have an area here in section 8 sections 1 in looking at those tips for completing the two claims forms you'll see that the prime provide as information is completed here we have room for the patient's medical record number in field 3b looking at our information we see that Abby's medical record number is listed so in our tips for completing one of the CMS rules for completing both the ubo for in the CMS 1500 form is that you have to use all cap so make sure your all caps button is on on your computer and you can enter Abby's medical record number into field 3b patient name is completed in field eight a patient address you'll find that in the patient data table as well as the birth date we know that Abby is a female we do have the admission date as March 7th so that information will be entered into field 12 condition codes you'll find them from more information about the condition codes in the step-by-step directions so take a look at those we don't have all of the information available to completely fill out this form to 100% accuracy so I'm not expecting to have this form and every single field completed with all of the information because you just don't have it so do the best that you can our line items start under descriptions in our first line item 4a d a B is room in board so I'm typing that in we have our service dates which is the date of the encounter our information gives us the total cost for those services so as you can see I'm just abstracting the information from the instructions for completing the exercise and I'm filling in the appropriate fields for the CMS 1500 form essentially you're doing the same thing you'll have the patient's health insurance information listed under the patient data table so you can abstract and check off which type of insurance the example that you're using again on the CMS 1500 form the first one is a B Addison so I'm gonna use that as my example as well patients name we're gonna list the last name first on this particular form patient's date of...