Claims : Submission

UB-04 (CMS 1450) Claim Form Instructions for Inpatient Hospital Services

These instructions are for the completion of the UB-04 claim for ForwardHealth. For complete billing instructions, refer to the National UB-04 Uniform Billing Manual prepared by the NUBC. The National UB-04 Uniform Billing Manual contains important coding information not available in these instructions. Providers may purchase the National UB-04 Uniform Billing Manual by calling 312-422-3390 or by accessing the NUBC website.

Members enrolled in BadgerCare Plus or Medicaid receive a ForwardHealth identification card. Always verify a member's enrollment before providing nonemergency services to determine if there are any limitations on covered services and to obtain the correct spelling of the member's name.

Note: Every code used on this claim form, even if the code is entered in a non-required form locator, is required to be a valid code. In addition, each provider is solely responsible for the truthfulness, accuracy, timeliness, and completeness of claims relating to reimbursement for services submitted to ForwardHealth.

When submitting paper claims, if the member has any other health insurance sources, providers are required to complete and submit an Explanation of Medical Benefits form, along with the completed paper claim.

Submit completed paper claims and the completed Explanation of Medical Benefits form, as applicable, to the following address:

ForwardHealth
Claims and Adjustments
313 Blettner Blvd
Madison WI 53784

Form Locator 1 — Provider Name, Address, and Telephone Number
Enter the name of the hospital submitting the claim and the hospital's complete practice location address. The minimum requirement is the hospital's name, city, state, and ZIP+4 code. Do not enter a Post Office Box or a ZIP+4 code associated with a PO Box. The name in Form Locator 1 must correspond with the NPI in Form Locator 56.

Form Locator 2 — Pay-to Name, Address, and ID (not required)

Form Locator 3a — Pat. Cntl # (optional)
Providers may enter up to 20 characters of the patient's internal office account number. This number will appear on the RA and/or the 835 transaction.

Form Locator 3b — Med. Rec. #
Enter the number assigned to the patient's medical/health record by the provider. This number will appear on the RA and/or the 835 transaction.

Form Locator 4 — Type of Bill
Exclude the leading zero and enter the three-digit type of bill code. The type of bill codes for inpatient hospital services include the following:

• 111 = Hospital, inpatient, admit through discharge claim.
• 851 = Special facility, critical access hospital, admit through discharge claim.

Form Locator 5 — Fed. Tax No.
Data are required in this form locator for OCR processing. Any information populated by a provider's computer software is acceptable data for this form locator. If computer software does not automatically complete this form locator, enter information such as the provider's federal tax identification number.

Form Locator 6 — Statement Covers Period (From - Through)
Enter both dates in MMDDYY format (for example, November 3, 2008, would be 110308). Include the date of discharge or death.

Form Locator 7 — Unlabeled Field (not required)

Form Locator 8 a-b — Patient Name
Enter the member's last name and first name, separated by a space or comma, in Form Locator 8b. Use Wisconsin's EVS to obtain the correct spelling of the member's name. If the name or spelling of the name on the ForwardHealth card and the EVS do not match, use the spelling from the EVS.

Form Locator 9 a-e — Patient Address
Data are required in this form locator for OCR processing. Any information populated by a provider's computer software is acceptable data for this form locator (for example, "On file"). If computer software does not automatically complete this form locator, enter information such as the member's complete address in field 9a.

Form Locator 10 — Birthdate
Enter the member's birth date in MMDDCCYY format (for example, September 25, 1975, would be 09251975).

Form Locator 11 — Sex (not required)

Form Locator 12 — Admission/Start of Care Date
Enter the admission date in MMDDYY format (for example, November 3, 2008, would be 110308).

Form Locator 13 — Admission Hr (not required)

Form Locator 14 — Priority (Type) of Admission or Visit
Enter the appropriate admission type for the services rendered. Refer to the UB-04 Billing Manual for more information.

Form Locator 15 — Point of Origin for Admission or Visit
Enter the code indicating the source of this admission. Refer to the UB-04 Billing Manual for more information.

Form Locator 16 — DHR (not required)

Form Locator 17 — Patient Discharge Status
Enter the code indicating disposition or discharge status of the member at the end service for the period covered on this claim. Refer to the UB-04 Billing Manual for more information.

Form Locators 18-28 — Condition Codes (required, if applicable)
Enter the code(s) identifying a condition related to this claim, if appropriate. Refer to the UB-04 Billing Manual for more information.

Form Locator 29 — ACDT State (not required)

Form Locator 30 — Unlabeled Field (not required)

Form Locators 31-34 — Occurrence Code and Date (required, if applicable)
If appropriate, enter the code and associated date defining a significant event relating to this claim that may affect payer processing. To indicate that Medicare Part A or Part B benefits were exhausted mid-stay, enter occurrence code "C3" and the date that Medicare benefits were exhausted. All dates must be printed in the MMDDYY format. Refer to the UB-04 Billing Manual for more information.

Form Locators 35-36 — Occurrence Span Code (From - Through) (not required)

Form Locator 37 — Unlabeled Field (not required)

Form Locator 38 — Responsible Party Name and Address (not required)

Form Locators 39-41 a-d — Value Code and Amount
Enter the applicable value code and associated amount. Enter covered days using value code "80" and enter the number of covered days in the corresponding amount field using two decimal places. (For example, to indicate one day, providers would enter "1.00;" to indicate 12 days, providers would enter "12.00.") Enter noncovered days using value code "81" and enter the number of noncovered days in the amount field using two decimal places. Do not count the day of discharge for covered days. For noncovered days, enter the total noncovered days by the primary payer. The sum of covered days and noncovered days must equal the number of days in the "From-Through" period in Form Locator 6.

To indicate that Medicare Part A or Part B benefits were exhausted mid-stay, enter value code "AB" and the amount that Medicare allowed. Refer to the UB-04 Billing Manual for more information.

To record birth weight for newborns, enter value code "54" and enter the newborn's birth weight in grams in the corresponding amount field.

Form Locator 42 — Rev. Cd.
Enter the appropriate four-digit revenue code as defined by the NUBC that identifies a specific accommodation or ancillary service. Refer to hospital publications or the UB-04 Billing Manual for information and codes.

Form Locator 43 — Description (not required)

Form Locator 44 — HCPCS/Rate/HIPPS Code (not required)

Form Locator 45 — Serv. Date (not required)

Form Locator 46 — Serv. Units
Enter the number of covered accommodation days or ancillary units of service for each line item. Do not count or include the day of discharge or death for accommodation codes.

Form Locator 47 — Total Charges (by Accommodation/Ancillary Code Category)
Enter the usual and customary charges pertaining to the related revenue code for the current billing period as entered in Form Locator 6.

Form Locator 48 — Non-covered Charges (not required)

Form Locator 49 — Unlabeled Field
Enter the "to" DOS in DD format only if the detail line includes a range of consecutive dates. The revenue code, procedure code and modifiers (if applicable), service units, and the charge must be identical for each date within the range.

Detail Line 23

PAGE ___ OF ___
Enter the current page number in the first blank and the total number of pages in the second blank. This information must be included for both single- and multiple-page claims.

CREATION DATE (not required)

TOTALS
Enter the sum of all charges for the claim in this field. If submitting a multiple-page claim, enter the total charge for the claim (i.e., the sum of all details from all pages of the claim) only on the last page of the claim.

Form Locator 50 A-C — Payer Name
Enter all health insurance payers here. Enter "T19" for Medicaid and the name of the commercial health insurance, if applicable. If submitting a multiple-page claim, enter health insurance payers only on the first page of the claim.

Form Locator 51 A-C — Health Plan ID (not required)

Form Locator 52 A-C — Rel. Info (not required)

Form Locator 53 A-C — Asg. Ben. (not required)

Form Locator 54 A-C — Prior Payments (not required)
This information is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer listed in Form Locator 50 A-C as an attachment(s) to their completed claim.

Form Locator 55 A-C — Est. Amount Due (not required)

Form Locator 56 — NPI
Enter the provider's NPI. The NPI in Form Locator 56 should correspond with the name in Form Locator 1.

Form Locator 57 — Other Provider ID (not required)

Form Locator 58 A-C — Insured's Name
Data are required in this form locator for OCR processing. Any information populated by a provider's computer software is acceptable data for this form locator (for example, "Same"). If computer software does not automatically complete this form locator, enter information such as the member's last name, first name, and middle initial.

Form Locator 59 A-C — P. Rel (not required)

Form Locator 60 A-C — Insured's Unique ID
Enter the member identification number. Do not enter any other numbers or letters. Use the ForwardHealth card or the EVS to obtain the correct member ID.

Form Locator 61 A-C — Group Name (not required)

Form Locator 62 A-C — Insurance Group No. (not required)

Form Locator 63 A-C — Treatment Authorization Codes (not required)

Form Locator 64 A-C — Document Control Number (not required)

Form Locator 65 A-C — Employer Name (not required)

Form Locator 66 — Dx (not required)

Form Locator 67 —Principal Diagnosis Code and Present on Admission Indicator
Enter the valid, most specific ICD code describing the principal diagnosis (for example, the condition established after study to be chiefly responsible for causing the admission or other health care episode). The principal diagnosis code selected must be the reason for admission. It should relate to one or more conditions or symptoms identified in the admission notes and/or admission work-up. Do not enter manifestation codes as the principal diagnosis; code the underlying disease first. The principal diagnosis may not include External Cause of Morbidity codes. The POA indicator is required for the primary diagnosis and must be included in the eighth digit of this field and be right justified. The diagnosis code must be left justified.

Form Locators 67A-Q — Other Diagnosis Codes and Present on Admission Indicator
Enter valid, most specific ICD diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received or the length of stay. Diagnoses that relate to an earlier episode and have no bearing on this episode are to be excluded. Providers should prioritize diagnosis codes as relevant to this claim. The POA indicator is required for secondary diagnoses and must be included in the eighth digit of this field and be right justified. The diagnosis code must be left justified.

Form Locator 68 — Unlabeled Field (not required)

Form Locator 69 — Admit Dx
Enter a valid, most specific ICD diagnosis code provided at the time of admission as stated by the physician.

Form Locator 70 — Patient Reason Dx (not required)

Form Locator 71 — PPS Code (not required)

Form Locator 72 — ECI (not required)

Form Locator 73 — Unlabeled Field (not required)

Form Locator 74 — Principal Procedure Code and Date (required, if applicable)
Enter the valid ICD procedure code that identifies the principal procedure performed during the period covered by this claim and the date on which the principal procedure described on the claim was performed.

Note: Most often, the principal procedure will be that procedure which is most closely related to the principal discharge diagnosis.

Form Locator 74a-e — Other Procedure Code and Date (required, if applicable)
If more than six procedures are performed, report those that are most important for the episode using the same guidelines for determining principal procedure (Form Locator 74).

Form Locator 75 — Unlabeled Field (not required)

Form Locator 76 — Attending
Enter the attending provider's NPI.

Form Locator 77 — Operating (not required)

Form Locators 78 and 79 — Other Provider Name and Identifiers (not required)

Form Locator 80 — Remarks (not required)

Commercial Health Insurance Billing Information

This information is not required on the claim.

Form Locator 81 a-d — CC
If the billing provider's NPI was indicated in Form Locator 56, enter the qualifier "B3" in the first field to the right of the form locator, followed by the appropriate 10-digit provider taxonomy code on file with ForwardHealth in the second field.

Note: Providers should use qualifier "PXC" when submitting an electronic claim using the 837I transaction. For further instructions, refer to the companion guide for the 837I transaction.