The Basics of UB04 Claim Forms

UB04 claim forms are use by facilities such as hospitals and clinics to submit medical insurance claims to insurance carriers as opposed to CMS1500 claim forms which are used by doctors and other medical providers to submit their claims. This includes drug and alcohol rehab facilities, eating order facilities and surgery centers. When a medical office is classified as a facility with an insurance carrier it is necessary to submit the claims on the UB04 which is much less familiar to most than the CMS1500 form. While most medical billers are very familiar with the CMS1500 form the UB04 form can seem very complicated.

The facility forms look similar to the CMS forms in that they are printed in red ink on white paper. They can be purchased where most CMS forms are available and they can also be submitted electronically as well as on paper.

The UBO4 requires a few fields which are totally different than fields required on the CMS form. Some of these fields include Rev Codes, type of bill, condition codes, and value codes which can make it terribly confusing to the biller only familiar with CMS forms. In order to get UB04 claims paid, the biller must learn what these fields are and how to complete them correctly for their situation. Many of the other fields on the UBO4 form are similar to the CMS form but these few different ones must be completed correctly.

Many of the boxes on this form are not required for other than hospital billing so the biller must know which boxes must be filled. In order to avoid time consuming resubmissions for denials of these claims you want to make sure they are completed correctly. Charges for claims files on UBO4 forms generally are higher than charges billed for many medical specialties so the amount of money tied up when claims are denied for incorrect information can be substantial.

It is not unusual for many of the clinics and facilities to be out of network with most insurance carriers and therefore not billing on the UB04 forms as they are not billing the insurance carriers, they are collecting the payment from the patients. But some of these patients are finding out that they have out of network benefits which means the insurance carrier would reimburse them for all or part of the expenses. The patients are then responsible for billing the insurance carriers. The insurance carriers may then demand that the claims be submitted on UB04 forms and it ends up the responsibility of the confused patient.