UB-04 Guide

UB-04 Guide (Overview):

This document encapsulates the general outline for completing a valid AlphaMCS UB-04 form. Listedbelow is a diagram of the UB-04 with highlighted fields which is necessary to successfully complete the form. You’ll also find in this document a Bill Types and Bill Type definitions as a reference.

  • 0100 is for outpatient ICF/MR claims only. Health-related but not a medical facility. Site must be marked as ICF in order to pay for this code.
  • 0101 is used for inpatient claims. Room & Board code rollup code from 101 and up. All of these will be marked as DRG, R&B or both. If both, then the service will pay for the overnight stay. If marked only as DRG then service will deny for non-covered ancillary service.
  • PRTF are non-hospitals that provide care for under-21 consumers, service codes such as 0911. The sight has to be marked as PRTF for these claims to adjudicate correctly. These will go to manual review due to the high dollar amount for these claims.

Helpful Notes:

HCPCS Code: H2020 and H0019 are the only codes to pay in this field (Box 44). H0019 for example has 3 different definitions and 3 different rates. MCOs can utilize local modifiers to determine which one of the three to use. This will be entered as H0019 XX. This will determine the rate to document on the claim which will then be removed prior to the 837 to State. The UB04 can also be used to submit claims for 3-way (YP821) state hospital contract. In this scenario, AlphaMCS will place this claim on an 837P for encounter claims from the MCO to NC Tracks. Providers submitting service YP821 in the HCPCS field on the service line within the UB04, any revenue code can be billed along with this service code.

Dating claims: enter the range in box 6 and leave the date in 45 blank. System will allocate the units based on dates in Box 6. Total number of days covered in the period should be entered in Box 46. If the claim is a continuing claim (bill type ending with 3), units should be the # of days in the period between the dates entered in box 6 (2/1 - 2/7 will be 7 days). If the claim is a discharge claim (bill type ending with 1 or 4), units should exclude the discharge date (2/1 - 2/7 will be 6 days).

‘Box 39’: only use 23, PML code (Patient Monthly Liability)

COB amount applied: MCOs will automatically receive 90 day extension.

ED Claims: Codes 0450-0459 are ED (emergency room) claims and must be billed with a rev code of 0131. 837I / UB04 claims submitted with bill type 0130 - 0139 will be treated as ED claims. ED claims cannot have R&B (room & board) code. If they do, then they will be denied with reason code (107 - invalid bill type). If a claim has R&B, it will become IP claim and 013x bill type is invalid.

58 Insured Name: this is not necessary since all consumers have their own policy number.

63 Treatment Auth Codes: this is not checked since the information is already pulled from the system/consumer record.

66 DX: This is the only DX reference field used, however for iClaims, this is not checked. This is only checked for the rare occasion the UB-04 is used to submit Professional Claims.

Manual Review Exception: Bill_type of 065X, 066x and ICF/MR code 0100 are exempt from manual review.

Valid AlphaMCS Bill Types and Type of Care

ID / Type / Care / ID / Type / Care / ID / Type / Care
1 / 110 / IP / 29 / 0111 / IP / 57 / 0139 / OP
2 / 111 / IP / 30 / 0112 / IP / 58 / 0140 / OP
3 / 112 / IP / 31 / 0113 / IP / 59 / 0141 / IP
4 / 113 / IP / 32 / 0114 / IP / 60 / 0142 / IP
5 / 114 / IP / 33 / 0115 / IP / 61 / 0143 / OP
6 / 117 / IP / 34 / 0116 / IP / 62 / 0144 / OP
7 / 118 / IP / 35 / 0117 / OP / 63 / 0145 / IP
8 / 131 / OP / 36 / 0118 / ICF / 64 / 0146 / OP
9 / 651 / ICF / 37 / 0119 / ICF / 65 / 0147 / OP
10 / 652 / ICF / 38 / 0120 / ICF / 66 / 0148 / OP
11 / 653 / ICF / 39 / 0121 / ICF / 67 / 0149 / IP
12 / 654 / ICF / 40 / 0122 / ICF / 68 / 0150 / OP
13 / 657 / ICF / 41 / 0123 / ICF / 69 / 0151 / ICF
14 / 658 / ICF / 42 / 0124 / RES / 70 / 0152 / IP
15 / 863 / RES / 43 / 0125 / RES / 71 / 0153 / OP
16 / 891 / RES / 44 / 0126 / RES / 72 / 0154 / OP
17 / 891 / RES / 45 / 0127 / RES / 73 / 0155 / OP
18 / 892 / RES / 46 / 0128 / RES / 74 / 0156 / OP
19 / 892 / RES / 47 / 0129 / RES / 75 / 0157 / OP
20 / 893 / RES / 48 / 0130 / RES / 76 / 0158 / OP
21 / 893 / RES / 49 / 0131 / RES / 77 / 0159 / OP
22 / 894 / RES / 50 / 0132 / RES / 78 / 0160 / OP
23 / 894 / RES / 51 / 0133 / RES / 79 / 0161 / OP
24 / 897 / RES / 52 / 0134 / RES / 80 / 0162 / OP
25 / 897 / RES / 53 / 0135 / RES / 81 / 0163 / IP
26 / 898 / RES / 54 / 0136 / RES / 82 / 0164 / OP
27 / 898 / RES / 55 / 0137 / IP / 83 / 0165 / RES
28 / 0110 / IP / 56 / 0138 / OP / 84 / 0166 / RES

Bill Types and their Description

Type of Bill / Description / IP/OP
0000 - 010x / Reserved by assignment by NUBC
011x / Hospital Inpatient (Including Medicare Part A) / IP
012x / Hospital Inpatient (Medicare Part B Only) / OP
013x / Hospital Outpatient / OP
014x / Hospital - Lab services provided to Non-Patients / OP
015x - 017x / Reserved by assignment by NUBC
018x / Hospital - Swing Beds / IP
019x - 020x / Reserved by assignment by NUBC
021x / Skilled Nursing - Inpatient (Including Medicare Part A) / IP
022x / Skilled Nursing - Inpatient (Medicare Part B) / OP
023x / Skilled Nursing - Outpatient / OP
024x - 027x / Reserved by assignment by NUBC
028x / Skilled Nursing - Swing Beds / IP
029x - 031x / Reserved by assignment by NUBC
032x / Home Health - Inpatient (plan of treatment under part B only) / OP
033x / Home Health - Outpatient (plan of treatment under Part A, Including DME / OP
034x / Home Health - Other (for medical and surgical services) / OP
035x - 040x / Reserved by assignment by NUBC
041x / Religious non medical health care institutions - Hospital IP / IP
042x / Reserved by assignment by NUBC
043x / Religious non medical health care institutions - Hospital OP / OP
044x - 064x / Reserved by assignment by NUBC
065x / Intermediate Care - Level I / IP
066x / Intermediate Care - Level II / IP
067x - 070x / Reserved by assignment by NUBC
071x / Clinic - Rural Health / OP
072x / Clinic - Hospital Based or Independent Renel Dialysis Center / OP
073x / Clinic - Free Standing / OP
074x / Clinic - Outpatient Rehabilitation Facility (ORF) / OP
075x / Clinic - Comprehensive Outpatient Rehab Facility (CORF) / OP
076x / Clinic - Community Mental Health Center / OP
077x - 078x / Reserved by assignment by NUBC
079x / Clinic - Other / OP
080x / Reserved by assignment by NUBC
081x / Special Facility - Hospice (non-Hospital Based) / OP
082x / Special Facility - Hospice (Hospital Based) / OP
083x / Special Facility - Ambulatory Surgery Center / OP
084x / Special Facility - Free Standing Birthing Center / IP
085x / Special Facility - Critical Access Hospital / OP
086x / Special Facility - Residential facility / IP
087x - 088x / Reserved by assignment by NUBC
089x / Special Facility - Other / IP
090x - 9999 / Reserved by assignment by NUBC

4th Digit Frequency Code

Frequency Code (x) / Description
0 / Non Payment/Zero / Use this code when the bill is submitted to a payer for informational purposes, the provider does not anticipate payment to result from submitting the bill; but needs to inform the payer of the non-reimbursable periods of confinement or termination of care.
1 / Admit through Discharge Claim (a) / Use this code when billing for a confined treatment or inpatient period. This will include bills representing a total confinement or course of treatment, and bills that represent an entire benefit period of the primary third party payer.
2 / Interim - First Claim / This code is to be used for the first of a series of bills to the same third party payer for the same confinement or course of treatment.
3 / Interim - Continuing Claim (b) / This code is to be used for when a bill for the same confinement or course of treatment has previously been submitted and it is expected that further bills for the same confinement or course of treatment will be submitted.
4 / Interim - Last Claim (b) / Use this code for the last of a series of bills, for which payment is expected, to the same third party payer for the same confinement or course of treatment
5 / Late Charge(s) Only / Use this code for submitting charges to the payer, which were received by the provider after the Admit Through Discharge, or the Last Interim Claim has been submitted
6 / Reserved by assignment by NUBC
7 / Replacement of Prior Claim (a) / This code is used when a specific bill has been issued for a specific Provider, Patient, Payer, Insured and "Statement Covers Period" and it needs to be restated in it's entirety, except for the same identify information. In using this code, the payer is to operate on the principal to void the original bill, and that the information present on the bill represents a complete replacement of the previously issued bill.
8 / Void/Cancel of Prior Claim (a) / This code reflects the elimination in its entirety of a previously submitted bill for a specific Provider, Patient, Payer, Insured and "Statement Covers Period." The provider may wish to follow a Void Bill with a bill containing the correct information when a Payer is unable to process a Replacement to a Prior Claim.