UB-04 claim form and instructions - AmeriHealth

1 Office of Management and Budget and the National Uniform Billing Committee have approved the UB-04 claim form , also known as the CMS-1450 form . The UB-04 claim form accommodates the National Provider Identifier (NPI) and has incorporated other important changes. Sample UB-04 forms for inpatient and outpatient claims can be found on pages 3 and UB-04 claim form and NPIThe UB-04 claim form includes several fields that accommodate the use of your NPI. Although the form accommodates the NPI, you may continue to report your current provider identification numbers in the appropriate areas of the form until otherwise notified.

2 If you have obtained your NPIs and submitted them to us, you must report them on the UB-04 claim form . If you have any questions regarding the UB-04 claim form , the NPI application process, or reporting your NPI to us, please call your Network Coordinator or Hospital/Ancillary Services Coordinator or contact Customer Service at 1-800-275-2583. UB-04 data field requirementsField location UB-04 DescriptionInpatientOutpatient1 Provider Name and AddressRequiredRequired2 Pay-To Name and AddressSituationalSituational3aPatient Control NumberRequiredRequired3bMedical Record NumberSituationalSituational4 Type of BillRequired Required 5 Federal Tax NumberRequiredRequired6 Statement Covers PeriodRequiredRequired7 Future UseN/AN/A8aPatient IDSituationalSituational8bPatient NameRequiredRequired9 Patient AddressRequiredRequired10 Patient BirthdateRequiredRequired11 Patient SexRequiredRequired12 Admission DateRequiredRequired.

3 If applicable13 Admission HourRequiredRequired, if applicable14 Type of Admission/VisitRequiredRequired15 Source of AdmissionRequiredRequired16 Discharge HourRequiredN/A17 Patient Discharge StatusRequiredRequired18-28 Condition CodesRequired, if applicableRequired, if applicable29 Accident StateSituationalSituational30 Future UseN/AN/A31-34 Occurrence Codes and DatesRequired, if applicableRequired, if applicable35-36 Occurrence Span Codes and DatesRequired, if applicableRequired, if applicable37 Future UseN/AN/A38 Responsible Party Name and AddressRequired, if applicableRequired, if applicable39-41 Value Codes and AmountsRequired, if applicableRequired, if applicable42 Revenue CodeRequiredRequired43 Revenue Code DescriptionRequiredRequiredNDC CodeRequired, if applicableRequired, if applicableUB-04 claim form and instructionsAmeriHealth HMO, Inc.

4 AmeriHealth Insurance Company of New Jersey QCC Insurance Company d/b/a AmeriHealth Insurance location UB-04 DescriptionInpatientOutpatient44 HCPCS/RatesRequired, if applicableRequired, if applicable45 Service DateN/ARequired46 Units of ServiceRequiredRequired47 Total Charges (By Rev. Code)RequiredRequired48 Non-Covered ChargesRequired, if applicableRequired, if applicable49 Future UseN/AN/A50 Payer Identification (Name)RequiredRequired51 Health Plan Identification NumberSituationalSituational52 Release of Info CertificationRequiredRequired53 Assignment of Benefit CertificationRequiredRequired54 Prior PaymentsRequired, if applicableRequired, if applicable55 Estimated Amount DueRequiredRequired56 NPIR equiredRequired57 Other Provider IDsOptionalOptional58 Insured s NameRequiredRequired59 Patient s Relation to the InsuredRequiredRequired60 Insured s Unique IDRequiredRequired61 Insured Group NameSituationalSituational62 Insured Group NumberSituationalSituational63 Treatment Authorization CodesRequired.

5 If applicableRequired, if applicable64 Document Control NumberSituationalSituational65 Employer NameSituationalSituational66 Diagnosis/Procedure Code QualifierRequired, if applicableRequired, if applicable67 Principal Diagnosis Code/Other Diagnosis CodesRequiredRequired68 Future UseN/AN/A69 Admitting Diagnosis CodeRequiredRequired, if applicable70 Patient s Reason for Visit CodeSituationalSituational71 PPS CodeSituationalSituational72 External Cause of Injury CodeSituationalSituational73 Future UseN/AN/A74 Principal Procedure Code/DateRequired, if applicableRequired, if applicable75 Future UseN/AN/A76 Attending Name/ID-Qualifier 1 GRequiredRequired77 Operating IDSituationalSituational78-79 Other IDSituationalSituational80 RemarksSituationalSituational81 Code-Code Field/Qualifiers*0-A0N/AN/A*A1-A4 SituationalSituational*A5-ABN/AN/AAC - Attachment Control numberSituationalSituationalAD-B0N/AN/A* B1-B2 SituationalSituational* _ _ _ _ _ _124 TYPEOF BILLF R OMTH R OUGH5 FED.

6 TAX N I123456789101112131415161718192021222312 34567891011121314151617181920212223 ABCABCDEFGHIJKLMNOPQ abcabcabcdADMISSIONCONDITIONCODESDATEOCC URRENCEOCCURRENCEOCCURRENCEOCCURRENCES PANOCCURRENCES PANCOD EDATECODECODECOD EDATECODETH R OUGHVALUE CODESVALUE CODESVALUE CODESCODEAMOUNTCODEAMOUNTCOD EAMOUNTTOTALS PRINCIPALP R R R R OCEDURENPICODEDATEDATEFIRSTNPIbL ASTFIRSTcNPIdL ASTFIRSTUB-04 CMS-1450710 BI R TH DATE11 SEX1213 HR14 TYPE15 SRCDATE16 DHR181920F R OM21252226282327 COD EF R OMDATEOTHERPR V IDTHECERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

7 OCEDURETHR OUGH29 AC DT30323133343536373839404142 RE V. C DESCRIPTION45 SE R V. DATE46 SE R V. UNITS47 TO TAL CHARGES48 NON-COVERED CHARGES4952 REL51 HEA LTH PLAN ID53 PRIOR PAYMENTS55 ES T. AMOUNT DUE56 NPI5758 INSURED S NAME59 INSURED SUNI Q UE ID61 G R OUP NAME62 INSURANCEG R OUP N DOCUMENTCONTR OLNUMBER65 EMPLOYERNAME66676869 ADMIT70 P ATIENT7273747576 ATTENDING80 REMARKSOTHERPROCEDUREa77 OPER ATING78 OTHER79 OTHER81 CCCRE A TION D A TE 3a P #24b. MED .REC . #44 HCPCS/ R ATE / HIPPSCODEP A G E OF APPROVED OMB NO.

8 Ea8 PATIENTNAME50 PAYERNAME63 TREATMENTAUTHORIZATION CODES6ST ATEMENTCO VERSPERIOD9 PATIENTADDRESS17 ST ATST ATEDXREASON DX71 PPSCOD EQUALL ASTL ASTN ational Uni formNUBC OCCURRENCEQUALQUALQUALLIC9213257 CODEDATEABCABCABCABCABC ababAny Hospital 123 Any Street Anytown NJ 08999 1234 0111 221234567 11 03 06 11 04 06 1234 Main Street Anytown NJ 08999 Patient ID if different from Sub Doe, John 03 20 1971 11 03 06M 08 3 3 12 01 Condition Codes Required Identifying Events 98765 RESERVED Country code if other than USAFUTURE USE PA RESERVED Occurrence and Occurrence Span Codes may be used to define a significant event that may affect payer processing John Doe1234 Main StreetAnytown.

9 NJ 08999A1 952 00 Value Codes and amounts required when necessary to process claim 0129 Semi-Private 0250 Pharmacy 0360 OR Services 2 400 00 50 00 100 00 Future Use 0 00 0 00 0 00 0 00 550 00 2222222222 1234567890 Secondary Tertiary Amount estimated to be due Required when indicated payer has paid amount to Provider Report HIPAA National Health Plan Identifier when mandatory Y Y 1 1 AmeriHealth Secondary Payer Tertiary Payer Any Hospital 456 Any Street Anytown NJ 08999 Doe, John Secondary Tertiary 18 ABC1234567800 Watch Repair, Inc. 1234 Watch Repair, Inc.

10 491234 02468 Secondary Tertiary 39104280 9 Use A through Q to report Other Diagnosis if applicable Reserved Reserved Secondary Tertiary May be used to report reason for visit May be used to report external cause of injury 2222222222 G2 1234569822 Reserved Smith David 3749 11 03 06 May be used to report additional information. B3 282N00000X DRG 1 INPATIENTRed = RequiredBlack = Situational/Required, if _ _ _ _ _ _124 TYPEOF BILLF R OMTH R OUGH5 FE D. TAX N I123456789101112131415161718192021222312 34567891011121314151617181920212223 ABCABCDEFGHIJKLMNOPQ abcabcabcdADMISSIONCONDITIONCODESDATEOCC URRENCEOCCURRENCEOCCURRENCEOCCURRENCES PANOCCURRENCES PANCOD EDATECODECODECOD EDATECODETH R OUGHVALUE CODESVALUE CODESVALUE CODESCODEAMOUNTCODEAMOUNTCOD EAMOUNTTOTALSPRINCI PAL P R R R R OCEDURENPICODEDATEDATEFIRSTNPIbL ASTFIRSTcNPIdL ASTFIRSTUB-04 CMS-1450710 BI R TH DATE11 SEX1213 HR14 TYPE15 SRCDATE16 DHR181920F R OM21252226282327 COD EF R OMDATEOTHERPR V IDTHE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND