BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire June 2012
UB-04 INFORMATION
UB-04 claim completion is for inpatient and outpatient services billed by hospitals, skilled nursing facilities, home health
agencies and other institutional providers. The data elements are listed as fields on the claim form.
Required information must be filled in completely, accurately, and legibly. If the information is inaccurate or incomplete, your
claim cannot be processed and will not be considered a “clean claim”. A clean claim has all the necessary data elements,
such as timely filing on industry standard paper forms (CMS-1500 or UB-04, or their successor forms), or by electronic
format, with no defect or impropriety. A submission which does not include all the necessary information, or for which GHC
must request additional information (for example, medical records, other coverage information, or subrogation information) is
not a clean claim until GHC receives the needed information.
A clean UB04 claim is considered to have the following data elements (numbered as shown on claim form):
1. Complete provider information to include name, address, city, state, zip code +4 and telephone number
3. Patient's account number
4. Type of bill
5. Federal tax ID number
6. Date(s) of service
8. Patient's complete name (to include middle initial when appropriate)
9. Patient's complete address
10. Patient's birth date
13. Admission hour
14. Type
15. SRC (Source of Admission)
16. Discharge hour
17. Discharge status
18-28. Condition codes
29. Accident Status
31-34 Occurrence codes & dates
42. Revenue codes
43. Revenue code description (optional)
44. HCPCS/CPT code corresponding to Rev Code in element 42*
45. Service Date
46. Days or units
47. Total Charges
50. Other insurance information (if applicable)
54. Amount Paid Prior
55. Balance Due (optional)
56. NPI
58. Insured's name
60. Patient Identification Number (ForwardHealth, Social Security or GHC six digit ID Number)
66. Principle Diagnosis
67A-Q. Diagnosis or nature of illness or injury
Present on Admission indicator (POA)
71. DRG number (only on inpatient claims)
72. E-Codes – External Cause of Injury (when appropriate)
76-79. Attending Provider’s NPI
81cc. Taxonomy
NOTE: Please utilize the appropriate claims form and follow standard Medicaid submission guidelines
for your INDUSTRY AND/OR PROVIDER type.
*This requirement is effective for claims received on or after July 1, 2010 regardless of date of service. Refer to
ForwardHealth Update No. 2010-22 for a list of Revenue codes that are exempt from this requirement.
[19]