Reduce your audit risk: How to analyze the UB-04

For an in-depth look at each element of the UB-04, join Janet Potter on Wednesday, October 25 from 1:00-2:30PM, ET, during our live show as she explains how to analyze your UB-04 data, how to incorporate findings from your review into your facility’s compliance program, and how to ensure that claims are complete and complaint. Click here to sign up!

Nursing facilities use UB-04 CMS-1450 or ANSI X12N 837-I to bill for covered Part B services.

The UB-04 is a claim form suitable for billing multiple third-party payers. All payers will not require the use of the same data elements, so check with each payer to identify its individual requirements. In general, SNFs are required to submit the UB-04 electronically to all payers, in the 837-I format. This form can be submitted through electronic billing software programs in batch billing or through direct data entry (DDE) through the MAC. A provider filing a UB-04 should retain the copy designated “Institution Copy” and submit the remaining copies to its MAC, managed care plan, or other insurer. If a provider omits any required data, the MAC will return the claim for correction (which is called return to provider or RTP).

The MAC will maintain the data on its history record. Data elements in the CMS uniform electronic billing specifications are consistent with the UB-04 data set to the extent that one processing system can handle both. The definitions are identical—although, in some situations, the electronic record contains more characters than does the corresponding item on the form because constraints on the form size are not applicable to the electronic record. Further, the revenue coding system is the same for the UB-04 and the electronic specifications.

UB-04 data elements

There are multiple data requirements for the UB-04. Each line contains a form locator (FL), and a narrative description is used to label the FL. A “Line” field is used so that you will know which line to use to record the information. For example, a provider should enter its provider name on line 1 in FL 1. It should enter its street address on line 2 in FL 1. The “Type” field identifies whether the data elements are alphabetic characters or numeric characters. Here is how to interpret entries in this field:

A = Alphabetic character

N = Numeric character

AN = Alphanumeric character

The “Size” field indicates how many characters are allowed within the field. For example, line 1 of FL 1 will allow a provider to enter up to 25 alphanumeric characters, whereas line 1 of FL 5 allows a provider to enter four alphanumeric characters.

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