Free Essay Example - UB-04 Billing Claim Form

Operating a healthcare facility is a complex task that involves critical roles such as the correct execution of the processing of patients' medical claims in compliance with insurance regulations. The absence of accurate records and a lack of comprehension of the appropriate forms lead to administrative chaos, frustrated patients, and a compromised reputation of the healthcare facility. One of the critical forms is the UB-04 claim form established by the Center for Medicare and Medicaid Services (CMS) as a standardized billing form to be utilized by institutional mental health or medical services providers. There are various medical claim forms used for billing, but the UB-04 is designed to be used by specific healthcare providers. They include hospices, hospitals, rural clinics, federal health centers, and general health centers, specialized health centers such as rehabilitation, renal care, and mental health clinics, and therapist centers such as speech therapy, occupational therapy, and physical therapy.

Is your time best spent reading someone else’s essay? Get a 100% original essay FROM A CERTIFIED WRITER!

Order now

The UB-04 also referred to as the CMS-1450 is the universal bill form required under the Health Insurance Portability and Accountability Act (HIPAA) and accepted by insurance providers. The form is used to submit a healthcare facility's charge of outpatient, inpatient, and non-patient services. It was created and maintained by the National Uniform Billing Committee (NUBC), a committee created to develop a standard set of data and a distinct billing form that could be utilized nationally by institutional healthcare providers (Vines-Allen, 2015). The original standard claims form was the UB-82, which underwent revisions and replaced by the UB-92. The UB-92 was later replaced by the current CMS-1450 or the UB-04. Presently, the NUBC's main role is to maintain the integrity of the set of data of the UB-04. The data set contains information necessary for every field on the UB-04. The UB-04 claim form consists of eighty-one fields, typically referred to as Form Locators. The revenue codes and the billing requirements for each Form Locator are continually revised by the NUBC, CMS and the State Uniform Billing Committees (SUBC) (Centers for Medicare & Medicaid Services, 2019).

The UB-04 shares similarities with the CMS-1500, both of which are claim forms, but various elements differentiate the two claim forms. In a situation where a medical professional, for instance, a doctor, bills their fees to an insurance carrier such as Medicare, the doctor submits the CMS-1500 Uniform Professional Healthcare Insurance Claims Form, also referred to as the HCFA. On the other hand, the cost of the healthcare facility's equipment use, beds, and ancillary items such as surgical supplies and sutures are billed to an insurance carrier through the Uniform Institutional Claim Form CMS-1450, also known as the UB-04. Thus, the uniform billing form, mostly referred to as the UB-04, is the standard for billing Medicare and all major insurance providers, but unlike the CMS-1500, the UB-04 contains a more complicated set of fields that specifies the types of services provided to the patients during their stay in the hospital (Eckman, 2019).

When a patient visits a hospital, the intake date of admission and the discharge hour and status are recorded on the UB-04 Claim Form. Additionally, patients are billed for a date-of-service on the UB-04 Claim Form when they visit a specialist or their primary care provider. In addition to the discharge status and hour and the intake date of admission, the UB-04 requires the utilization of codes which are not present on the CMS Professional 1500 form, which are maintained by the National Uniform Billing Committee. The codes unique to the UB-04 claim form include conditions codes, revenue codes, value codes, occurrence codes and occurrence span codes (Vines-Allen, 2015). The UB-04 is the present version of the paper uniform bill used by healthcare providers, which contains elements of data recognized as crucial for processing claims in the paper environments. The UB-04 form has eighty-one numbered fields referred to as Form Locators (FLs), each with its own identifying number as well as general fields for data elements which are needed occasionally.

The Form Locators in the UB-04 are categorized and can be viewed in four sections, in which information on the patient, the healthcare facility, and the doctors involved in the care of the patient is recorded. In the first section of the UB-04, information on the patient, healthcare facility, admission, occurrence, discharge and value information is recorded. In the Form Locator one through seventeen, the UB-04 facilitates the collection of detailed information on the admission of the patient, the healthcare facility, the patient control number, medical record number, and patient discharge. In the fields eighteen to thirty, condition codes are recorded that provide information on the circumstances of the claim, which may influence the processing of the insurance provider. Subsequently, value and occurrence codes are recorded in the Form Locator thirty one to forty-one, and they provide information used to determine the need for medical services by the patient's insurance provider (Centers for Medicare & Medicaid Services, 2019). The UB-04, via the condition, value, and occurrence codes, is used by insurance providers in their benefit determination process.

In section two, the Form Locators forty-two to forty-nine assist in the collection of charge information. Information provided in this section presents detailed data on service units, service date, the charges submitted, which include revenue description and code, non-covered charges, total charges, Healthcare Common Procedure Coding System (HCPCS) code and rates, and National Drug Code (NDC) (Vines-Allen, 2015). Charge data captured during a patient's visit are collected and used in printing a comprehensive detailed statement, which is used to complete fields forty-two to forty-nine of the UB-04. The charges captured throughout a patient's visit are posted via the Charge Description Master, with each item in the master being associated with an appropriate HCPCS code, category of revenue code, and other charge information. The comprehensive detailed statement records every charge individually (Centers for Medicare & Medicaid Services, 2019); thus Form Locator 42 to 49 on the UB-04 facilitate and require that all charges during a patient's stay are captured and classified in revenue code categories.

The purpose of Section three of the UB-04 claim form is to provide information on the insurance provider, the insured patient, the patient's employer, and authorization information. In the fields numbered fifty to sixty-five in the claim form, data on the primary, secondary and tertiary insurance providers that are responsible for payments on the claims is recorded. Tertiary insurance providers are the insurance companies that are responsible for payment of claims after the primary and secondary insurance providers have issued a determination of payment (Vines-Allen, 2015). Information captured in the Form Locator fifty to sixty-five consists of the insured patient's name and identification number, the patient's employer, the insurance provider's name, group name, and number and treatment authorization code. Subsequently, in the final section, section four of the UB-04, information on procedure and diagnosis is recorded in the fields sixty-six to seventy-four of the claim form. This information is associated with the charges submitted. Furthermore, information concerning attending and other doctors, the insurance provider's name, address, and signature is captured in the fields seventy-six to eighty-one (Centers for Medicare & Medicaid Services, 2019).

Apart from providing a standardized format to acquire the information stated above, that is instrumental in the effective and fast processing of insurance claims, the UB-04, as stated earlier, is a paper version that offers a place holder for elements required by its current electronic version, ASC X12N 837I version 5010. Over the years as the number of paper claims decrease, with an increase in electronic claims, both the UB-04 and its electronic counterpart have played a critical role in the improvement of clinical data reporting, enabling the reporting of procedure codes and diagnosis codes, and assisting in differentiating between admitting diagnosis codes, principal diagnosis codes, external cause of injury codes and patient reason for visit codes (Eckman, 2019). As a result, the UB-04, through the distinctions it offers, also serves the purpose of improving the comprehension of clinical data in effect facilitating the proper monitoring of rates of mortality for various illnesses, length of stay in the hospital for various conditions, and outcomes of specific treatment options, as well as the clinical reasons for why a patient required healthcare services.

Ultimately, the fundamental purpose of the UB-04 claim form is to offer simplicity in filing claims through its standardized format. Unlike previous claim forms that were niche in their focal pointed and complicated, the UB-04 is more accommodating, universal and clear as well as applying to the majority of healthcare facilities in the country. Through its comprehensive fields, the UB-04 facilitates the collection of data vital to the effective and efficient processing of claims as well as providing an avenue to understand clinical data concerning various issues affecting the healthcare industry.

References

Centers for Medicare & Medicaid Services. (2019, January 11). Medicare Claims Processing Manual. Retrieved from Centers for Medicare & Medicaid Services: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf

Eckman, J. (2019, April 23). Demystifying the UB-04 Claim Form. Retrieved from Denials Management: https://fixmyclaim.com/demystifying-the-ub-04-claim-form/

Vines-Allen, D. (2015). Comprehensive Health Insurance: Billing, Coding and Reimbursement. Upper Saddle River: Prentice Hall.