1450 Claim Form – Fill Out and Use This PDF

The Centers for Medicare & Medicaid Services (CMS) announced the approval of the new CMS-1450 (UB04) Health Insurance Claim form used by institutional providers. The UB04 claim form was revised by the National Uniform Claim Committee (NUCC) to accommodate reporting of the National Provider Identifier (NPI) and additional codes.

Most of the data descriptions and values were not changed on the UB04 claim form; however many data locations have changed, along with bill type processing.

Additional enhancements include better alignment with the electronic HIPAA ASC X12N 837-Institutional Transaction Standard.

BlueCross BlueShield of Tennessee’s (BCBST’s) timeline for transitioning to the revised format follows:

On these dates	Providers can:
Prior to 3/1/07	only submit CMS-1450 (UB92)
	version
3/1/07 – 5/22/07	submit either the CMS-1450
	(UB92) or CMS-1450 (UB04);
	with appropriate print alignment
	on respective form
5/23/07	only use the CMS-1450 (UB04)
	version; CMS-1450 (UB92)
	version discontinued and will be
	returned unprocessed

This communication provides general instructions to be used as a guide for completing the new UB04 claim form fields identified below. Providers are encouraged to refer to the billing sections of the BlueCross BlueShield of Tennessee and BlueCare® provider administration manuals for complete billing guidelines.

Important Critical Changes

Some form locator fields have been deleted, added, had field length changes or divided into two lines to allow reporting of supplemental information or both the BCBST provider identification number (PIN) and National Provider Identifier (NPI).

•Do not print the CMS-1450 (UB92) format on the new CMS-1450 (UB04) claim form. Claims will be returned unprocessed if submitted without the appropriate print alignment. Check with your billing vendor or system administrator to ensure you have the updated format.

•Prior to submitting claims with your NPI in form locator 56, it is vital that it be set up in the BCBST provider database.

•If filing with your BCBST PIN, the PIN (Form Locator 57) and the BCBST subscriber ID (Form Locator 60) must both be on the same payer line.

•Do not put your PIN in Form Locator 51.

•Only ICD-9 codes are acceptable for use in diagnosis and procedure code fields (Form Locators 67, 67 a-q and 74. Claims submitted with out-of-date codes will be returned and rejected for invalid code.

•Principal diagnosis code is now required for all inpatient and outpatient claims.

•For attending, operating and other physicians, the attending Physician Name and NPI/Qual/ID should be entered in Form Locator 76, 77 and 78 respectively. If Name is submitted but neither NPI nor ID is available, enter (‘OTH000’) in the ID field.

Rejected Claims

In March 2006, BlueCross BlueShield of Tennessee began a phased transition period in order to process paper submitted institutional claims.

During the transition, institutional providers may submit either the UB92 or UB04 claim form. However, rejected institutional claims may be returned on the new UB04 claim form regardless of the version filed.