HOW TO COMPLETE A UB04 FORM

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In this overview, we'll guide you through the essential steps, ensuring a clear understanding of each element, providing insights from experienced industry professionals on how to complete a UB04 form.

Obtain the UB-04 Form.

The CMS-1450 form, famously known as UB04 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. It is also used for billing of institutional charges to most Medicaid State Agencies.

Get a copy of the UB-04 form. You can often find this form through the National Uniform Billing Committee (NUBC) or use billing software that supports UB-04.

Fill Out the UB-04 Form

• Patient Information:

  Start by entering the patient's demographic details, including name, address, and birthdate. Ensure accurate insurance information is provided.

• Billing Provider Details:

  Include information about the facility or individual submitting the claim. Provide the National Provider Identifier (NPI) and Tax ID.

• Type of Bill:

  Specify the appropriate Type of Bill code corresponding to the services provided. It is made up of 3 digits.

• Admission and Discharge Dates:

  Record the dates of the patient's admission and discharge.

• Diagnosis and Procedure Codes:

  Assign accurate ICD-10 diagnosis and procedure codes for services rendered.

• Revenue Codes:

  Indicate the revenue codes corresponding to each service or procedure. Refer to your payer’s provider manual.

• Service Description and Charges:

  Detail the services provided, along with associated charges. Break down charges by revenue code and service description.

• Total Charges and Payments:

  Summarize the total charges and any payments received.

• Provider's Signature:

  Ensure the form is signed by the authorized provider.

• Attachment of Supporting Documents:

  Include any necessary supporting documents, such as medical records or prior authorization.