EZ 2000 Manual - Medical UB-04 Form
Medical UB-04 Claim Form
The UB04 claimform is are used for institutional claims and is included in Version 12.0. The claim forms are printed; they are not sent in e-claims.
Printing
If you are using the UB-04 claimform, it is helpful to have a background image for setup puposes. The background image should not print because preprinted forms should be used. To see the background, save the file UB04.jpg in your A to Z folder, then add it to the Claim Form.
UB04 Information
Information specific to the UB04 Claim Form is entered on the Edit Claim window under the Medical UB-04 tab. Check with the insurance company to verify the values they accept for each of the values in this section.
Type of Bill (3 digit): Enter a three-digit code using the table below.
| Code | Description |
|---|---|
| 1st Digit – Type of Facility | |
| 1 | Hospital |
| 2 | Skilled Nursing Facility |
| 3 | Home Health> |
| 4 | Christian Science (Hospital) |
| 5 | Christian Science (Extended Care) |
| 6 | Intermediate Care |
| 7 | Clinic |
| 2nd Digit – Bill Classifications | |
| (Excluding Clinics & Special Facilities) | |
| 1 | Inpatient |
| 3 | Outpatient |
| 4 | Other (For Hospital Referenced Diagnostic Services, or Home Health Not Under a Plan of Treatment) |
| 5 | Intermediate Care, Level I |
| 6 | Intermediate Care, Level II |
| 7 | Intermediate Care, Level III |
| 8 | Swing Beds |
| (Clinics Only) | |
| 1 | Rural Health |
| 2 | Hospital Based or Independent Renal Dialysis Center |
| 3 | Free Standing |
| 4 | Other Rehabilitation Facility (ORF) |
| 9 | Other |
| (Special Facility Only) | |
| 1 | Hospice (Non-Hospital Based) |
| 2 | Hospice (Hospital Based) |
| 3 | Ambulatory Surgery Center (ASC) |
| 4 | Freestanding Birthing Center |
| 3rd Digit – Frequency | |
| 1 | Admit through Discharge Claim |
| 2 | Interim – First Claim |
| 3 | Interim – Continuing Claims |
| 4 | Interim – Last Claim |
| 5 | Late Charge only |
| 6 | Adjustment of Prior Claim |
| 7 | Replacement of Prior Claim |
| 8 | Void/Cancel of Prior Claim |
Admission Type: 1-Emergency, 2-Urgent, 3-Elective, 4-Newborn, 5-Trauma Center, 6-8 Reserved, 9-Information Not Available.
Admission Source:
| Code | Description |
|---|---|
| Except Newborns (Field 20) | |
| 1 | Physician Referral |
| 2 | Clinic Referral |
| 3 | HMO Referral |
| 4 | Transfer from a Hospital |
| 5 | Transfer from a Skilled Nursing Facility (SNF) |
| 6 | Transfer from Another Health Facility |
| 7 | Emergency Room |
| 8 | Court/Law Enforcement |
| 9 | Information Not Available |
| 10 | Transfer from Psych Substance Abuse or Rehab Hospital |
| 11 | Transfer from a Critical Access Hospital |
| Additional Source of Admission Codes for Newborns (Field 20) | |
| 1 | Normal Delivery |
| 2 | Premature Delivery |
| 3 | Sick Baby |
| 4 | Extramural Birth |
| 5 | Information Not Available |
Patient Status:
01Discharged to Home or Self-Care (Routine Discharge)02Discharged/Transferred to Another Short-Term General Hospital
| Code | Definition |
|---|---|
| 03 | Discharged/Transferred to an SNF |
| 04 | Discharged/Transferred to an Intermediate Care Facility (ICF) |
| 05 | Discharged/Transferred to Another Type of Institution (Including Distinct Parts) or Referred for Outpatient Services to Another Institution |
| 06 | Discharged/Transferred to Home Under Care of Organized Home Health Service Organization |
| 07 | Left Against Medical Advise or Discontinued Care |
| 08 | Discharged/Transferred to Home Under Care of Home IV Therapy Provider |
| 09 | Admitted as an Inpatient to this Hospita |
| 20 | Expired (or Did Not Recover-Christian Science Patient) |
| 30 | Still a Patient or Expected to Return for Outpatient Services |
| 31 – 39 | Still Patient to be Defined at State Level, if Necessary |
| 40 | Expired at Home (for Hospice Care Only) |
| 41 | Expired in a Medical Facility such as a Hospital, SNF, ICF or Freestanding Hospice (for Hospice Care Only) |
| 42 | Expired, Place Unknown (for Hospice Care Only) |
| 50 | Discharged to Hospice-Home |
| 51 | Discharged to Hospice-Medical Facility |
Condition Codes: Use this condition code:
| If the admission/service was: | |
| C1 | Approved as billed |
| C2 | Automatically approval as billed based on focused review |
| C3 | Partially approval |
| C4 | Denied |
| C5 | Is post-payment review applicable |
| C6 | Required admission pre-authorization |
| C7 | Had extended authorization (was authorized for an extended length of time, but the services provided have not been reviewed) |
| If the reason for the claim change is: | |
| D0 | Changes to service dates |
| D1 | Changes to charges |
| D2 | Changes in revenue codes/HCPCS/HIPPS rate codes |
| D3 | Second or subsequent interim prospective payment system (PPS) bill |
| D4 | Changes in ICD-9-CM diagnosis and/or procedure codes |
| D5 | Cancel to correct health insurance claim number (HICN) or provider identification number |
| D6 | Cancel only to repay a duplicate or Office of Inspector General (OIG) overpayment |
| D7 | Change to make Medicare the secondary payer |
| D8 | Change to make Medicare the primary payer |
| D9 | Any other change |
| E0 | Change in patient status |
| G0 | Distinct medical visit |
| H0 | Delayed filing, statement of intent submitted |
| H2 | Discharge by a hospice provider for cause |
| W2 | Duplicate of original bill |
| W3 | Level I appeal |
| W4 | Level II appeal |
| W5 | Level III appeal |
Value Codes: Use these codes.
| If you are submitting a claim for: | |
| 01 | Most common semi-private room rate |
| 02 | Hospital has no semi-private rooms |
| 04 | Professional component charges, which are combined billed |
| 05 | Professional component included in charges and also billed separately to carrier |
| 06 | Medicare blood deductible |
| 08 | Medicare lifetime reserve amount (in the first calendar year) |
| 09 | Medicare co-insurance amount (in the first calendar year in billing period) |
| 10 | Medicare lifetime reserve amount (in the second calendar year) |
| 11 | Medicare co-insurance amount (in the second calendar year) |
| 12 | A working-aged beneficiary/spouse with employer group health plan |
| 13 | An end-stage renal disease (ESRD) beneficiary in a Medicare coordination period with an employer group health plan |
| 14 | No fault, including auto/other |
| 15 | Workers’ compensation |
| 16 | Public Health Service or other federal agency |
| 30 | Pre-admission testing |
| 31 | Patient liability amount |
| 32 | Multiple patient ambulance transport |
| 37 | Units of blood furnished |
| 38 | Blood deductible units |
| 39 | Pints of blood replaced |
| 40 | New coverage not implemented by HMO (for inpatient claims only) |
| 41 | Black lung |
| 42 | Veteran’s Affairs |
| 43 | Disabled beneficiary under age 65 with large group health plan |
| 44 | Amount provider agreed to accept from the primary insurer when this amount is less than charges but greater than the primary insurer’s payment |
| 45 | Accident hour* |
| 46 | Number of grace days |
| 47 | Any liability insurance |
| 48 | Hemoglobin reading |
| 49 | Hematocrit reading |
| 50 | Physical therapy visits |
| 51 | Occupational therapy visits |
| 52 | Speech therapy visits |
| 53 | Cardiac rehabilitation visits |
| 54 | Newborn birth weight in grams |
| 55 | Eligibility threshold for charity care |
| 56 | Skilled nurse – home visit hours (HHA only) |
| 57 | Home health aide – home visit hours (HHA only) |
| 58 | Arterial blood gas (PO2/PA2) |
| 59 | Oxygen saturation |
| 60 | Home Health Agency branch MSA |
| 61 | Place of residence where service is furnished (home health aide and hospice) |
| 66 | Medicaid spend down amount |
| 67 | Peritoneal dialysis |
| 68 | Epoetin Alfa (EPO) – drug |
| 69 | State charity care precert |
| 80 | Covered days |
| 81 | Non-covered days |
| 82 | Co-insurance days |
| 83 | Lifetime reserve days |
| A0 | Special zip code reporting |
| A1 | Deductible payer A |
| B1 | Deductible payer B |
| C1 | Deductible payer C |
| E1 | Deductible payer D; discontinued 3/1/07 |
| F1 | Deductible payer E; discontinued 3/1/07 |
| G1 | Deductible payer F; discontinued 3/1/07 |
| A2 | Co-insurance payer A |
| B2 | Co-insurance payer B |
| C2 | Co-insurance payer C |
| E2 | Co-insurance payer D |
| F2** | Co-insurance payer E; code discontinued 3/1/07 |
| G2** | Co-insurance payer F; discontinued 3/1/07 |
| A3 | Estimated responsibility payer A |
| B3 | Estimated responsibility payer B |
| C3 | Estimated responsibility payer C |
| D3 | Estimated responsibility patient |
| D4 | Clinical trial number assigned by National Library of Medicine (NLM)/National Institutes of Health (NIH) |
| E3 | Discontinued, effective with UB-04 implementation 3/1/07 |
| F3 | Discontinued, effective with UB-04 implementation 3/1/07 |
| G3 | Discontinued, effective with UB-04 implementation 3/1/07 |
| A4 | Covered self-administrable drugs–emergency |
| A5 | Covered self-administrable drugs not self-administrable in form and situation furnished to patient |
| A6 | Covered self-administrable drugs–diagnostic study and other |
| A7 | Copayment payer A; this code is used only on paper claims; for electronic 837 claim, use Loop ID 2320 CAS segment (Claim Adjustment Group Code “PR”). |
| B7 | Copayment payer B; this code is used only on paper claims; for electronic 837 claim, use Loop ID 2320 CAS segment (Claim Adjustment Group Code “PR”). |
| C7 | Copayment payer C; this code is used only on paper claims; for electronic 837 claim, use Loop ID 2320 CAS segment (Claim Adjustment Group Code “PR”). |
| E7 | Copayment payer E; discontinued 3/1/07 |
| F7 | Copayment payer F; discontinued 3/1/07 |
| G7 | Copayment payer G; discontinued 3/1/07 |
| G8 | MSA or Core-Based Statistical Area (CBSA) number (or rural state code) of the facility where inpatient hospice service is delivered. Report the number in dollar portion of the form locator right-justified to the left of the dollar/cents delimiter. |
| **For Medicare, use this code only for reporting Part B co-insurance amounts. | |
