The following provider types should bill using the ub04 claim form. New revenue code in 100x series for outdoorwilderness behavioral healthcare july 20, 2016 conference call minutes. The texas medicaid provider procedures manual is the providers principal source of information about texas medicaid. No other publication governmental or privatecommercial can be considered authoritative. How to maximize your pt billing by using the right cpt. Which billing manual should i use based on my provider type. The ub04 uniform billing form is the standard claim form that any institutional provider can use for the billing of medical and mental health claims. Sep 12, 2014 to download a copy of the eohhs acute hospital rfa and contract. Cms1500 paper claim form billing instructions october 2015 cms1500 paper claim form computerbased training. Health first colorado ub04 inpatientoutpatient billing. Hospitals must use appropriate tob when billing for serious reportable events. Beneficiary coinsurance cms iom, publication 2, medicare benefit policy manual, chapter, section 80. This form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing multiple. Location of the arbitration the arbitration hearing will be held in the city and state in which the anthem office identified in the address block on the signature page to the agreement is located.
When youre billing for gait training 97116, mechanical traction 97012, or manual therapy 97140, the therapeutic intent is pretty cut and dried. With that in mind, lets walk through a few examples. The measures that apply to ry2015 and ry2016 reporting are. Ub04 billing instructions provider knowledge base partners. R form prescribed by cms for the medicare program and is only accepted from medicare claims processing manual crosswalk cms. Dialysis billing manual 619 federally qualified health centerrural health center fqhcrhc 1119 home health billing manual 819 hospice billing manual 619 indian health services ihs 1019 ip. Although the instructions that follow are based on the ub04 paper claim form, they are also intended as a guideline for. Sep 15, 2015 are to be supplemented with the information and codes in the uniform billing manual for the ub04. The ub04 is a claim form that is utilized for hospital services and select residential services. Anthem blue cross and blue shield provider manual nv page 10 of 190 revised. 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. Effective january 1, 2016, acp is considered a facetoface service between a practitioner and a patient on advance directives and it is a standalone billable rhc.
If submitting ub04s with multiple pages, please follow these guidelines. Inpatientoutpatient hospital billing manual colorado. Listed below is a series of manuals detailing the situational data elements and planspecific values that must be included in. Chapter 1 general billing requirements pdf chapter 1 crosswalk pdf chapter 2 admission and registration requirements pdf chapter 2 crosswalk pdf. August 2015, effective november 15, 2015 july 31, 2016 b. Instructions for completion inpatientoutpatient billing manual colorado.
The instructions describe what information must be entered in each of the block numbers of. Kaiser permanente provider manual 2016 8 section 5. Other claim form types will be rejected and returned to the provider. Independent fqhcs bill on cms1500 claim form to part b. Refer to the general provider information manual for general. Home health providers who choose to submit their claims on paper forms must use the national uniform billing committee nubc ub04 claim form. Coinsurance and deductible applies and will be based on the charges reported on the revenue code 052x service line with modifier cg. Most available revenue codes will be accepted on an ltc 837i claim but only. Chapter 6 inpatient part a billing and snf consolidated billing pdf chapter 6 crosswalk pdf chapter 7 snf part b billing including inpatient part. Fqhcs billing under air, coinsurance is 20% of charges for fqhc services.
Providers can refer to the national uniform billing code website at. Paper ub04 claims submitted for ltc services will not be accepted. The revision date and transmittal number apply only to red 2550uniform bill ub form cms1450 for billing ub92. Florida blue is implementing new billing requirements for drug services reported on both rofessional p cms1500837p and institutional ub04837i claims effective november 14, 2016. The ub04 data specifications manual is the official source of data specifications adopted by the nubc and contains codes.
Jan 3, 2016 identify the provider manual sections regarding ub04 claim form january 2016 diagnosis codes and icd10 pcs codes on a claim to ensure the left border of the revenue code field box 42 to the right border of box odm hospital billing guidelines ohio department of medicaid. Ihs638 facility will use the ub04 claim form when billing the air. Ub 04 medicare discharge status code cms 1500 claim form. The manual is regularly updated to reflect the most recent policy and procedure changes. To view a sample home health ub04 claim form, see appendix a. Clinics should go to their state gov website to obtain a the rhc billing manual for the state. Providers should refer to the billing manual for medical and surgical services medicare claims, should be mailed to the correct fiscal agent address located submitting the paper ub04 claim form to the health first colorado for fqhc and home health billing manual colorado. Updates are generally available the month following the effective date of the change.
Effective january 1, 2016, acp is considered a facetoface service between a practitioner and a patient on advance directives and it is a standalone billable rhc visit. Although developed by the centers for medicare and medicaid cms, the form has become the standard form used by all insurance carriers. This form, also known as the ub 04, is a uniform institutional provider bill suitable for. Ry2015 eohhs technical specifications manual for mass. Although the form is similar in appearance to the older version of the facility claim form, ub92, a number of fields have been moved or expanded and. However, the movement intervention codes think 97110, 97112, and 97530 are a bit trickier. Ub04 change implementation calendar effective date form. Enter the fourdigit code from the national ub04 manual for the provider type that indicates the type of bill using the following guidance by provider type. Ub04 special billing instructions for inpatient services. Fromthrough billing providers must not mix the tarauthorized and nontarauthorized services in the same fromthrough billing period. The details of the following changes are contained in the ub04 manual or in the minutes. The ub 04 claim form is a hardcopy facility claim form recently redesigned to accommodate various changes to facility claims filing necessitated by current and upcoming governmental initiatives. Rhc medicaid billing can vary depending on the state billing rules. When submitting your claim, you need to identify the member.
The members payor is responsible for payment of claims in accordance with your agreement. The ub 04 is a claim form that is utilized for hospital services and select residential services. For electronic billing, please refer to the maryland medicaid 837i electronic companion guide, which can be found on our website. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual. Utility billing ub program, the following options are available. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. Billing a continuation claim using the ub04 claim form. Although the form is similar in appearance to the older version of the facility claim form, ub 92, a number of fields have been moved or expanded and. Anthem blue cross and blue shield provider and facility manual. Providers should refer to the code of colorado regulations, program rules 10 c. Ub04 special billing instructions for outpatient services. Billing manuals colorado department of health care. Providerbased fqhcs bill under parent provider to part a on cms ub04 claim form. Summary of inpatient hospital claims grouper versions.
Attachment to ub04 billing instructions notice 1208. Important medicaid integrity information medicaid integrity program az medicaid integrity program faq welcome to wyoming medicaid manuals and bulletins. Travel and lodging paper claim form billing instruction updated aug. This form, also known as the ub04, is a uniform institutional provider bill suitable for. Ihstribal provider billing manual chapter creation. Mar, 2017 outpatient hospital lab and xray claim example. Chapter 25 completing and processing the form cms1450 data set. Ub04 special billing instructions for inpatient services 1. Access levels select the checkbox next to each access level to grant access to the corresponding menu within the msi utility billing system that the user logging in with this password should have rights to access. Please use the national ub04 manual for specific codes. Billing manuals south dakota department of social services. Ub04 paper claim form billing instructions october 2015 ub04 paper claim form computerbased training.
This manual, ed by the american hospital association, is the only official source of ub data. Fl02 billing providers designated payto id 4 an 25. Therefore, the information in this manual is subject to change, and the manual is updated as new billing information is implemented. Some states will require medicaid claims to be submitted on 1500 claim forms while others will require medicaid to be billed on the ub04 form. The alabama medicaid provider billing manual is a practical guide to assist medicaidenrolled providers in receiving reimbursement. Dialysis billing manual 619 federally qualified health centerrural health center fqhcrhc 1119 home health billing manual 819 hospice billing manual 619. The displayed claim form is a sample and is for illustration purposes only. Coding and billing units outpatient hospital ub04 form. Ub 04 medicare discharge status code,01 discharged to. Chapter 1 general billing requirements pdf chapter 1 crosswalk pdf. This section illustrates billing examples of medicaremedi cal crossover claims for part b services billed to part a contractors submitted hard copy on a ub04.
Kaiser permanente provider manual 2016 10 section 5. The instructions are organized by the corresponding boxes or form locators on the paper ub04 and detail only those data elements required for medical assistance ma paper claim billing. Rhc billing 101 basics of rural health center services. See multiple tars in the tar completion section of this manual. Snf part b billing including inpatient part b and outpatient fee schedule pdf chapter 7. Refer to the general provider information manual for general billing information. Write the medicaid payment rate for each cpt code listed, and write the per unit amount. Long term care service billing requirements and coding. Ub04 billing guide for promise inpatient hospitals purpose of the document the purpose of this document is to provide a blockbyblock reference guide to assist the. The ub04 claim form is a hardcopy facility claim form recently redesigned to accommodate various changes to facility claims filing necessitated by current and upcoming governmental initiatives.