Claims : Submission

UB-04 (CMS 1450) Claim Form Instructions for Personal Care Services

Use the following claim form completion instructions, not the form locator descriptions printed on the claim form, to avoid claim denial or inaccurate claim payment. Complete all required form locators, as appropriate. Do not include attachments unless instructed to do so.

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 ForwardHealth 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. Refer to the Online Handbook in the Provider area of the ForwardHealth Portal for more information about verifying enrollment.

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.

Submit completed paper claims 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 provider submitting the claim and the provider's complete practice location address. The minimum requirement is the provider'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 billing provider number in Form Locator 57.

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. # (optional)
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
Enter the three-digit type of bill code. Type of bill codes for personal care providers include the following:

32X: Home Health — Services under a plan of treatment.

• 321: Inpatient admit through discharge claim
• 322: Interim bill — first claim
• 323: Interim bill — continuing claim
• 324: Interim bill — final claim

34X: Home Health — Services not under a plan of treatment.

• 341: Inpatient admit through discharge claim
• 342: Interim bill — first claim
• 343: Interim bill — continuing claim
• 344: Interim bill — final 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 (e.g., "Same"). 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 (e.g., 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 (e.g., "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 (e.g., September 25, 1975, would be 09251975).

Form Locator 11 — Sex
Specify the member's gender as male with an "M" or female with an "F." If the member's gender is unknown, enter "U."

Form Locator 12 — Admission Date (not required)

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. All dates must be printed in the MMDDYY format. Refer to the UB-04 Billing Manual for more information.

Form Locator 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 (not required)

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 personal care publications or the UB-04 Billing Manual for information and codes.

Form Locator 43 — Description
Do not enter any dates in this form locator.

Form Locator 44 — HCPCS/Rate/HIPPS Code
Enter the appropriate five-digit procedure code and the appropriate modifier. Refer to the personal care service area for appropriate modifiers.

Form Locator 45 — Serv. Date
Enter the single "from" DOS in MMDDYY format in this form locator.

Form Locator 46 — Serv. Units
Enter the number of units of service or visits where appropriate. For each DOS, indicate whole units rounded to the nearest 15 minutes (15 minutes = 1 unit).

Form Locator 47 — Total Charges (by Accommodation/Ancillary Code Category)
Enter the usual and customary charges for each line item.

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 (not required)

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)

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

Form Locator 56 — NPI(not required)

Form Locator 57 — Other Provider ID
Enter the provider number in this form locator. The provider number in Form Locator 57 should correspond with the name in Form Locator 1.

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 (e.g., "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 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 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 (e.g., the condition established after study to be chiefly responsible for causing the admission or other health care episode). 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.

Form Locator 68 — Unlabeled Field (not required)

Form Locator 69 — Admit Dx (not required)

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 (not required)

Form Locator 74 a-e — Other Procedure Code and Date (not required)

Form Locator 75 — Unlabeled Field (not required)

Form Locator 76 — Attending (not required)

Form Locator 77 — Operating (not required)

Form Locators 78 and 79 — Other Provider Name and Identifiers
Enter the referring provider's NPI, followed by "DN" in the qualifier field and the last and first names of the provider in the appropriate fields. If a rendering provider is required on the claim, enter the rendering provider's NPI, followed by "82" in the qualifier field and the last and first names of the provider in the appropriate fields.

Form Locator 80 — Remarks (not required)

Form Locator 81 a-d — CC (not required)