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SAMPLE INPATIENT UB-04 FORM 3a PAT. CNTL b. MED. REC. 5 FED. TAX NO. 8 PATIENT NAME 9 PATIENT ADDRESS a 11 SEX OCCURRENCE CODE DATE c ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT TYPE OF BILL STATEMENT COVERS PERIOD FROM THROUGH b 10 BIRTHDATE CONDITION CODES d e 29 ACDT 30 STATE VALUE CODES AMOUNT 42 REV. The UB-04 form has been used exclusively for institutional billing beginning May 23 2007. Sample UB-04 forms for inpatient and outpatient services are enclosed. The UB-04 Claim Form and NPI ...

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What is the name of the electronic equivalent of the UB-04 paper claim?

The electronic counterpart to the UB-04 is the 837I. The UB-04 and 837I are used for all health care claims. The P in 837P stands for professional because the 837P is used to submit professional component (physician) claims. The paper claim form used by physicians is the CMS-1450.

What is the electronic version of the CMS-1500?

The ANSI ASC X12N 837P (Professional) Version 5010A1 is the current electronic claim version.

What is the UB-04 claim form used for?

The CMS-1450 form (aka UB-04 at present) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

What is the difference between UB-04 and CMS-1500?

The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities. This would include things like surgery, radiology, laboratory, or other facility services. The HCFA-1500 form (CMS-1500) is used to submit charges covered under Medicare Part B.

How do I print a UB-04 form?

Printing UB-04 Claims Select the UB-04 claims. ... Correct any errors in the UB-04 claims. ... Add additional information to the UB-04 forms. ... Right-click on an insurance claim or insurance carrier and select Print UB04 to print the UB-04 form and send it to your insurance carrier in the mail.

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Who submits a UB04 form?

All institutional providers may use the UB-04 form to bill claims, such as hospitals, specialists, mental health centers, hospices, rehabs, organ procurement organizations and therapy services.

What is the electronic version of UB-04?

The UB-04 is the electronic version of CMS-1450 only.

What setting uses UB-04 form?

The UB-04 (CMS 1450) is a claim form used by hospitals, nursing facilities, in-patient, and other facility providers. A specific facility provider of service may also utilize this type of form.

What is the difference between a CMS 1500 form and UB-04 form?

When a physician has a private practice but performs services at an institutional facility such as a hospital or outpatient facility, the CMS-1500 form would be used to bill for their services. The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities.

Do hospitals use CMS 1500 form?

But healthcare professionals or physicians use this form to get their payments done on time. So, CMS 1500 is used only by the physicians and not hospitals. Whereas UB-04 or CMS 1450 form is used by hospitals with 81 field locators to enter all the required details like HCPCS codes, NPI, Tax ID, etc.

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What is the name of the electronic equivalent of the UB-04 paper claim?

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