Ub94 Claim Form Details

If you're like most small business owners, you're always looking for ways to save money on taxes. One great way to do this is by using the Ub 94 form. This form can help you take advantage of tax breaks and deductions that you may not be aware of. In this blog post, we'll explain what the Ub 94 form is and how it can help you save money on taxes. We'll also provide a few tips for completing the form correctly.

You'll find it useful to know how much time you'll need to fill in this ub 94 form and exactly how lengthy the form is.

QuestionAnswer
Form NameUb 94 Form
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesub94 claim form, ub 94 form, HCPCS, ub94 form

Form Preview Example

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

Required/Optional

Remarks

1

Billing Provider Information

 

Required

 

Four-lines of information:

 

 

 

 

 

Name

 

NOTE: This is the physical

 

 

 

Address

 

address of the location where

 

 

 

City/State/Zip

 

services were provided. This is

 

 

 

Phone: 123-123-1234

 

not a Post Office Box address.

 

 

 

 

2

Pay-To Provider Information

 

Situational

 

Required if the pay-to

 

 

 

 

 

provider address is different

 

NOTE: A PO Box is acceptable

 

 

 

than the billing provider.

 

in this space.

 

 

 

 

3a

Patient Control Number

 

Optional

 

Enter your patient account

 

 

 

 

 

number, if provided this

 

 

 

 

 

number will be returned on

 

 

 

 

 

the EOB/EOP.

3b

Medical/Health Record Number

 

Optional

 

May be used for the patient’s

 

 

 

 

 

medical record number. This

 

 

 

 

 

field is not reported back on

 

 

 

 

 

the EOB/EOP.

4

Bill Type

 

Required

 

Use NUBC taxonomy tables

 

 

 

 

 

for acceptable values

 

 

 

 

 

NOTE: This field plays a role

 

 

 

 

 

in the adjudication of the

 

 

 

 

 

claim. An incorrect value in

 

 

 

 

 

this field could result in an

 

 

 

 

 

incorrect payment.

5

Federal Tax ID

 

Required

 

Enter number WITHOUT

 

 

 

 

 

hyphen: NNNNNNNNN

 

 

 

 

 

NOTE: Forms are scanned

 

 

 

 

 

into electronic files; a hyphen

 

 

 

 

 

may result in payment

 

 

 

 

 

inaccuracy or rejection of

 

 

 

 

 

your claim.

6

Statement Covers From and

 

Required

 

Outpatient = enter the first

 

Thru Dates

 

 

 

and last dates of services

 

 

 

 

 

billed on this claim.

 

FORMAT: MMDDYY without

 

 

 

Inpatient = enter admit and

 

dashes, slashes or spaces.

 

 

 

discharge date for this

 

 

 

 

 

admission. If interim billing

 

 

 

 

 

is being performed, enter the

 

 

 

 

 

first and last dates of the

 

 

 

 

 

services that are being billed

 

 

 

 

 

on the form.

7

Unassigned

 

Not Used

 

 

8a

Patient ID#

 

Required

 

Enter patient’s DCHP ID#:

 

 

 

 

 

STAR: 9 numeric characters

 

 

 

 

 

CHIP: 9 alpha-numeric

 

 

 

 

 

characters with alpha

Page 1 of 9

 

 

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

Required/Optional

Remarks

 

 

 

 

 

character appearing in the lead

 

 

 

 

 

position.

8b

Patient Name

 

Required

 

Patient name:

 

 

 

 

 

Last, First Middle

 

 

 

 

 

Sample: SMITH, MARY JO

9a

Patient Address

 

Required

 

Patient’s street address

9b

Patient City

 

Required

 

Patient’s city

9c

Patient State

 

Required

 

Patient’s state – 2-digit USPO

 

 

 

 

 

abbreviation required

9d

Patient Zip Code

 

Required

 

Patient’s zip code – 5 digits

 

 

 

 

 

are required. 9-digit is

 

 

 

 

 

optional. If 9-digit is used

 

 

 

 

 

DO NOT use a hyphen.

9e

Patient County Code

 

Optional

 

If used, must use codes

 

 

 

 

 

provided by American

 

 

 

 

 

National Standards Institute in

 

 

 

 

 

ISO3166

10

Date of Birth

 

Required

 

Enter date: MMDDYYYY

 

 

 

 

 

without hyphens, slashes or

 

 

 

 

 

spaces

11

Sex

 

Required

 

M = male

 

 

 

 

 

F = female

 

 

 

 

 

U = unknown

12

Admission or Start of Care Date

 

Required on both inpatient

 

Enter date: MMDDYY

 

 

 

and outpatient claims

 

without hyphens, slashes or

 

 

 

 

 

spaces

13

Admission Hour

 

Required

 

Use NUBC taxonomy tables

 

 

 

 

 

for acceptable values: 00

 

 

 

 

 

through 23 to define the hour

14

Admission Type

 

Required on Inpatient

 

1 = emergency

 

 

 

 

 

2 = urgent

 

 

 

Optional on Outpatient

 

3 = elective

 

 

 

 

 

4 = newborn

 

 

 

 

 

5 = trauma

 

 

 

 

 

9 = information not available

15

Admission Source

 

Required

 

Use NUBC taxonomy tables

 

 

 

 

 

for acceptable values

16

Discharge Hour

 

Required on inpatient

 

Use NUBC taxonomy tables

 

 

 

where bill type end is a 1,

 

for acceptable values: 00

 

 

 

2, 3, or 4.

 

through 23 to define the hour

 

 

 

Optional on outpatient

 

 

17

Discharge Status

 

Required on inpatient

 

Use NUBC taxonomy tables

 

 

 

 

 

for acceptable values

 

 

 

Not Used on outpatient

 

 

18-28

Condition Codes

 

Situational, but required

 

Use NUBC taxonomy tables

 

 

 

where the condition code

 

for acceptable values

Page 2 of 9

 

 

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

 

Required/Optional

 

 

Remarks

 

 

 

 

 

 

 

 

 

applies to the bill

 

 

29

Accident State

 

Situational, but required

 

Use the 2-digit STATE

 

 

 

where applicable. Always

 

abbreviation to designate the

 

 

 

required when E-level

 

State in which the accident

 

 

 

ICD9 codes are used.

 

occurred.

30

Unassigned

 

Not Used

 

 

31 a & b

Occurrence Code and Date

 

Situational, but required

 

Use NUBC taxonomy tables

through

 

 

where the occurrence code

 

for acceptable values

34 a & b

 

 

applies to the bill

 

 

35 a & b

Occurrence Span Code and

 

Situational, but required

 

Use NUBC taxonomy tables

through

Dates

 

where the occurrence code

 

for acceptable values

36 a & b

 

 

and span dates apply to the

 

 

 

 

 

bill

 

 

37

Unassigned

 

Not Used

 

 

38

Responsible Party Name and

 

Not Used

 

Providers may complete this

 

Address

 

 

 

 

field, but it will not be used

 

 

 

 

 

 

for claims processing and this

 

 

 

 

 

 

information will not be

 

 

 

 

 

 

reported back.

 

 

 

 

 

 

If used:

 

 

 

 

 

 

Name

 

 

 

 

 

 

Address

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

If a 9-digit zip is used, it must

 

 

 

 

 

 

be formatted as nnnnn-nnnn

 

 

 

 

 

 

with hyphen displayed.

39a,b,c,d

Value Codes and Amounts

 

Situational, but required

 

Use NUBC taxonomy tables

through

 

 

where the occurrence code

 

for acceptable values

41a,b,c,d

 

 

and span dates apply to the

 

 

 

 

 

bill

 

 

42

Revenue Code

 

Required on both inpatient

 

Use NUBC taxonomy tables

 

 

 

and outpatient claims

 

for acceptable values

43

Description

 

Required on paper claims

 

Use the Standard

 

 

 

 

 

 

Abbreviation as determined

 

 

 

 

 

 

by NUBC UB04

 

 

 

 

 

 

specifications

44

HCPCS Code or Rate

 

REQUIRED as shown to

 

Inpatient:

 

 

 

the right

 

Rev Codes 0100 through 0219

 

 

 

 

 

 

and the 100X series must

 

 

 

 

 

 

show the unit room rate.

 

 

 

 

 

 

Outpatient:

 

 

 

 

 

 

Revenue Codes 0450 through

 

 

 

 

 

 

0459 must be HCPCS coded

 

 

 

 

 

 

with the applicable level of

 

 

 

 

 

 

care describing the visit.

 

 

 

 

 

 

99281 – Level 1

 

 

 

 

 

 

99282 – Level 2

Page 3 of 9

 

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

 

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

Required/Optional

 

Remarks

 

 

 

 

 

 

 

 

 

99283 – Level 3

 

 

 

 

99284 – Level 4

 

 

 

 

99285 – Level 5

 

 

 

 

See Appendix A below for a

 

 

 

 

list of all UB Rev Codes that

 

 

 

 

must be HCPCS-coded on the

 

 

 

 

Outpatient UB04 form.

45

Service Date

Inpatient: Do not Use

 

MMDDYY

 

 

Outpatient: Required

 

 

46

Service Units

REQUIRED as shown to

 

Inpatient:

 

 

the right

 

Rev Codes 0100 through 0219

 

 

 

 

and the 100X series must

 

 

 

 

show the number of days

 

 

 

 

billed for each

 

 

 

 

accommodation.

 

 

 

 

Outpatient:

 

 

 

 

UB Rev Code 0762 requires

 

 

 

 

number of hours not to exceed

 

 

 

 

23. Other codes may be

 

 

 

 

populated at provider’s

 

 

 

 

discretion.

47

Total Charges

Required

 

 

48

Non-Covered Charges

Situational, this

 

Inpatient Claims: The charges

 

 

information is required if

 

represented in field 47 that

 

 

some of the charges

 

fall on dates of service that

 

 

shown in field 47 are not

 

were denied by utilization

 

 

covered or if some dates

 

management, must be

 

 

of services reflected in the

 

reflected in this column.

 

 

charges in field 47 have

 

 

 

 

been denied by DCHP

 

 

 

 

utilization management.

 

 

49

Unassigned

Not Used

 

 

50

Payer Name

Required

 

Use multiple lines (a,b,c) if

 

 

 

 

there is more than one payer.

 

 

 

 

DCHP will always be the

 

 

 

 

payer of last resort. Providers

 

 

 

 

must bill other insurance and

 

 

 

 

reflect the payment and denial

 

 

 

 

on the bill send to DCHP.

51

Health Plan ID

Not required for STAR or

 

NOTE: This field may

 

 

CHIP claims

 

become mandatory once

 

 

 

 

health plans are assigned their

 

 

 

 

own National Plan Identifier.

52

Release of Information

Required

 

Y = Yes

 

 

 

 

N = No

53

Benefits Assigned

Required

 

Y = Yes

 

 

 

 

 

Page 4 of 9

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

Required/Optional

Remarks

 

 

 

 

 

All CHIP and STAR claims

 

 

 

 

 

must indicate YES.

54

Prior Payments

 

Situational

 

Enter any dollar amount paid

 

 

 

 

 

by the payer on this claim

55

Estimated Amount Due

 

Not Required

 

 

56

NPI

 

Required

 

The 10-digit NPI number of

 

 

 

 

 

the BILLING PROVIDER

 

 

 

 

 

identified in field 1 on the

 

 

 

 

 

UB04

57

Other Billing Provider

 

Not Required

 

 

58

Insured Name

 

Required

 

Name of the insured person

 

 

 

 

 

for the insurance shown in

 

 

 

 

 

field 50.

 

 

 

 

 

For STAR and CHIP this will

 

 

 

 

 

always be the PATIENT.

59

Insured Relationship to Patient

 

Required

 

Use NUBC taxonomy tables

 

 

 

 

 

for acceptable values

 

 

 

 

 

For STAR and CHIP this will

 

 

 

 

 

always = 18

60

Insured’s Unique ID

 

Required

 

Insurance ID# assigned by the

 

 

 

 

 

health plan of payer to the

 

 

 

 

 

insured person

 

 

 

 

 

CHIP: 9-character numbers

 

 

 

 

 

starting with a alpha character

 

 

 

 

 

and followed by 8 numeric

 

 

 

 

 

characters

 

 

 

 

 

STAR: 9-numeric characters

61

Group Name

 

Required for other

 

Enter the name of group,

 

 

 

insurance

 

which is will usually be the

 

 

 

 

 

employer through which the

 

 

 

Not Required for STAR

 

insurance is received.

 

 

 

and CHIP

 

 

 

 

 

 

 

For STAR and CHIP, this

 

 

 

 

 

field can be left blank or can

 

 

 

 

 

be populated with “DCHP”.

62

Insurance Group Number

 

Required for other

 

Enter the group ID# assigned

 

 

 

insurance

 

by the applicable payer.

 

 

 

Not Required for STAR

 

For STAR and CHIP this field

 

 

 

and CHIP

 

can be left blank.

63

Treatment Authorization Codes

 

Situational

 

If prior authorization code

 

 

 

 

 

was given for the services

 

 

 

 

 

represented in the claim, enter

 

 

 

 

 

than number in this space.

64

Document Control Number

 

Situational

 

If re-submitting a claim that

 

 

 

 

 

was previously adjudicated,

Page 5 of 9

 

 

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

 

Required/Optional

 

 

Remarks

 

 

 

 

 

 

 

 

 

 

Required only for a claim

 

 

enter the Internal Control

 

 

 

re-submission

 

 

Number shown on the DCHP

 

 

 

 

 

 

Explanation of Payment

 

 

 

 

 

 

(EOP) form.

65

Employer Name

 

Required for other

 

 

Enter the name of the

 

 

 

insurance

 

 

employer who provides the

 

 

 

 

 

 

insurance to the person shown

 

 

 

Not Required for STAR

 

 

in field 58

 

 

 

and CHIP

 

 

 

66

Diagnosis Code Qualifier

 

Required

 

 

Should always = 9 to indicate

 

 

 

 

 

 

ICD9 code.

For all codes entered in field 67 through 74 decimals are assumed and should not be stated.

67

Principal or Present on

 

Required

 

 

Inpatient: Enter the principal

 

Admission Code

 

 

 

 

diagnosis as defined by CMS

 

 

 

 

 

 

Outpatient: Enter the

 

 

 

 

 

 

diagnosis code that describes

 

 

 

 

 

 

the reason for the visit

67 A-Q

Other Diagnosis Codes

 

Situational

 

 

Enter all other final diagnosis

 

 

 

 

 

 

codes applicable to the visit or

 

 

 

 

 

 

addressed in the visit or that

 

 

 

 

 

 

explain why the services

 

 

 

 

 

 

being billed were performed.

69

Admit Diagnosis

 

Inpatient: Required

 

 

Enter the applicable ICD9

 

 

 

 

 

 

codes representing the reason

 

 

 

Outpatient: Not Required

 

 

for admission

70

Patient’s Reason for Visit

 

Inpatient: Not Used

 

 

Enter the applicable ICD9

 

 

 

 

 

 

codes.

 

 

 

Outpatient: Required for

 

 

 

 

 

 

Emergency Room, not

 

 

 

 

 

 

required otherwise

 

 

 

71

PPS Code

 

REQUIRED for DRG-

 

 

Enter the applicable DRG

 

 

 

based hospitals, otherwise

 

 

code determined by the

 

 

 

this field in not required.

 

 

provider that applies to this

 

 

 

 

 

 

claim.

72

External Cause of Injury Code

 

Situational

 

 

Enter the applicable E-level

 

 

 

 

 

 

ICD9 code if the treatment

 

 

 

 

 

 

was related to an accident

73

Unassigned

 

Not Used

 

 

 

74

Principal Procedure

 

Situational

 

 

Input the ICD9 surgical

 

 

 

 

 

 

procedure code and the date

 

 

 

 

 

 

of the surgery applicable to

 

 

 

 

 

 

the treatment represented on

 

 

 

 

 

 

the claim

74 a-e

Other Procedure

 

Situational

 

 

Input the ICD9 surgical

 

 

 

 

 

 

procedure code and the date

 

 

 

 

 

 

of the surgery applicable to

 

 

 

 

 

 

the treatment represented on

 

 

 

 

 

 

the claim

75

Unassigned

 

Not Used

 

 

 

Page 6 of 9

 

 

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

 

Required/Optional

 

 

Remarks

 

 

 

 

 

 

76

Attending Provider Name and

 

Required

 

NPI

 

Identifiers

 

 

 

 

Attending provider’s NPI

 

 

 

 

 

 

number

 

NOTE: There are 4 distinct

 

 

 

 

 

 

fields within this box. Each

 

 

 

 

QUAL

 

field must be completed as

 

 

 

 

Enter the qualifier of 1D

 

shown in the far right column.

 

 

 

 

followed by Attending

 

 

 

 

 

 

Provider’s TPI #

 

 

 

 

 

 

LAST

 

 

 

 

 

 

Last name of Attending

 

 

 

 

 

 

Provider

 

 

 

 

 

 

FIRST

 

 

 

 

 

 

First name of Attending

 

 

 

 

 

 

Provider

77

Operating Provider Name and

 

Situational

 

NPI

 

Identifiers

 

 

 

 

Operating provider’s NPI

 

 

 

 

 

 

number

 

NOTE: There are 4 distinct

 

 

 

 

 

 

fields within this box. Each

 

 

 

 

QUAL

 

field must be completed, if

 

 

 

 

Enter the qualifier of 1D

 

applicable, as shown in the far

 

 

 

 

followed by Operating

 

right column.

 

 

 

 

Provider’s TPI #

 

 

 

 

 

 

LAST

 

 

 

 

 

 

Last name of Operating

 

 

 

 

 

 

Provider

 

 

 

 

 

 

FIRST

 

 

 

 

 

 

First name of Operating

 

 

 

 

 

 

Provider

78

Other Provider Name and

 

Situational – if applicable

 

NPI

 

Identifiers

 

use this field for

 

Referring provider’s NPI

 

 

 

REFERRING PROVIDER

 

number

 

NOTE: There are 4 distinct

 

 

 

 

 

 

fields within this box. Each

 

 

 

 

QUAL

 

field must be completed, if

 

 

 

 

Enter the qualifier of 1D

 

applicable, as shown in the far

 

 

 

 

followed by Referring

 

right column.

 

 

 

 

Provider’s TPI #

 

 

 

 

 

 

LAST

 

 

 

 

 

 

Last name of Referring

 

 

 

 

 

 

Provider

 

 

 

 

 

 

FIRST

 

 

 

 

 

 

First name of Referring

 

 

 

 

 

 

Provider

79

Other Provider Name and

 

Situational

 

NPI

 

Identifiers

 

 

 

 

Other provider’s NPI number

Page 7 of 9

 

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

 

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

Required/Optional

 

Remarks

 

 

 

 

 

 

NOTE: There are 4 distinct

 

 

QUAL

 

fields within this box. Each

 

 

Enter the qualifier of 1D

 

field must be completed. If

 

 

followed by Other Provider’s

 

applicable, as shown in the far

 

 

TPI #

 

right column.

 

 

 

 

 

 

 

LAST

 

 

 

 

Last name of Other Provider

 

 

 

 

FIRST

 

 

 

 

First name of Other Provider

80

Remarks Field

Situational

 

Used when in the judgment of

 

 

 

 

the provider, the information

 

 

 

 

is needed to substantiate the

 

 

 

 

medical treatment and it is not

 

 

 

 

supported elsewhere within

 

 

 

 

the claim data set.

81

Code-Code Field

Situational

 

Used in accordance with the

 

 

 

 

NUBC taxonomy set forth in

 

 

 

 

the NUBC UB04

 

 

 

 

specifications manual and

 

 

 

 

published by the American

 

 

 

 

Hospital Association.

Change Log:

Date

Version

Changes

5-17-07jc

1.0

Initial DRAFT version, posted on website but also used internally to vet

 

 

requirements.

5-27-07jc

1.1

Updated as discussed internally. Most critical changes were to the

 

 

following fields 44 and 46. In addition, Appendix A was added at the end

 

 

of this document.

 

 

 

 

 

 

 

 

 

Page 8 of 9

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication

Field Requirements for CMS-1450 Claims Forms (UB94)

For Driscoll Children’s Health Plan

Field

Description

Required/Optional

Remarks

APPENDIX A: UB Rev Code That Required HCPCS Coding for all Outpatient Bill Types

(Revenue Codes not applicable to an outpatient claim or that do not require HCPCS coding on an outpatient claims are

omitted from the following list)

Disclaimer: Inclusion in the following does not imply that the Revenue Code is a covered service.

Please refer to applicable Medicaid regulations and to the UB04 Manual published by the American

Hospital Association for details.

CODES

CODES

CODES

CODES

CODES

CODES

029X

035X

045X

056X

077X

098X

030X

040X

046X

057X

090X

210X

031X

041X

047X

061X

091X

 

032X

042X

048X

073X

092X

 

033X

043X

054X

074X

096X

 

034X

044X

055X

075X

097X

 

All providers that use the UB04 form are strongly encouraged to subscribe the UB04 Manual published by the American Hospital Association. To the fullest extent possible, Driscoll Children’s Health Plan uses these specifications in processing claims.

Page 9 of 9

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

Not Used = information not used by DCHP in processing the claim, data placed here will be ignored during claim adjudication