The following sample UB-04 claim forms for PDN services provided by NIP are available:
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 form locators unless otherwise indicated. 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 Web site.
ForwardHealth members receive a ForwardHealth identification card when initially enrolled in BadgerCare Plus. 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: 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
6406 Bridge Rd
Madison WI 53784-0002
Form Locator 1 — Provider Name, Address, and Telephone Number
Enter the name of the provider submitting the claim and the practice location
address. The minimum requirement is the provider's name, city, state, and ZIP+4
code. The name in Form Locator 1 should 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 ForwardHealth 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 ForwardHealth Plus 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
first digit identifies the type of facility. The second digit classifies the
type of care. The third digit indicates the billing frequency. Providers
should enter one of the following for the type of bill:
Form Locator 5 — Fed. Tax No.
Data is 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) (not required)
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 identification card and the EVS do not match, use the
spelling from the EVS.
Form Locator 9 a-e — Patient Address
Data is 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 that the recipient is male with an "M" or female with an "F." If the
recipient's sex is unknown, enter "U."
Form Locator 12 — Admission Date (not required)
Form Locator 13 — Admission Hr (not required)
Form Locator 14 — Admission Type (not required)
Form Locator 15 — Admission Src (not required)
Form Locator 16 — DHR (not required)
Form Locator 17 — Stat (not required)
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 publications
or the UB-04 Billing Manual for information and codes.
Form Locator 43 — Description (not required)
Do not enter any dates in this form locator.
Form Locator 44 — HCPCS/Rate/HIPPS Code (not required)
Enter the appropriate five-digit procedure code, followed by the modifiers.
Enter the appropriate five-digit procedure code, followed by the modifiers. Modifiers may include start-of-shift modifiers, professional status modifiers, and the case coordination modifier. No more than four modifiers per detail line may be entered. Refer to the NIP area of the Online Handbook for appropriate modifiers.
Form Locator 45 — Serv. Date
Enter the single "from" date of service (DOS) in MMDDYY format in this form
locator.
Form Locator 46 — Serv. Units
Enter the number of covered accommodation days or ancillary units of service for each line item.
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. A range of consecutive dates may be
indicated only if the revenue code, the procedure code (and modifiers, if
applicable), the service units, and the charge were 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 (required, if applicable)
Enter the actual amount paid by commercial health insurance. (If the dollar
amount indicated in Form Locator 54 is greater than zero, "OI-P" [other insurance] must be
indicated in Form Locator 80.) If the commercial health insurance denied the
claim, enter "000." Do not enter Medicare-paid amounts in this field.
If submitting a multiple-page claim, enter the amount paid by commercial health insurance only on the first page of the 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 is 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 59 A-C — P. Rel (not required)
Form Locator 60 A-C — Insured's Unique ID
Enter the member's 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 — Prin. Diag. Cd.
Enter the valid, most specific ICD-9-CM code (up to five digits)
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 "E" (etiology)
codes.
Form Locators 67A-Q — Other Diag. Codes
Enter valid, most specific ICD-9-CM diagnosis codes (up to five digits)
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.
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 74a-e — Other Procedure Code and Date (not required)
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 (not required)
Enter the other provider's NPI.Form Locator 80 — Remarks (enter information when applicable)
Commercial Health Insurance Billing Information
Commercial health insurance coverage must be billed prior to billing
ForwardHealth, unless the service does not require commercial health insurance
billing as determined by ForwardHealth.
When the member has dental ("DEN"), Medicare Cost ("MCC"), Medicare + Choice ("MPC") insurance only, or has no commercial health insurance, do not indicate an OI explanation code in Form Locator 80.
When the member has Wausau Health Protection Plan ("HPP"), BlueCross & BlueShield ("BLU"), Wisconsin Physicians Service ("WPS"), Medicare Supplement ("SUP"), TriCare ("CHA"), vision only ("VIS"), a health maintenance organization ("HMO"), or some other ("OTH") commercial health insurance, and the service requires commercial health insurance billing, then one of the following three OI explanation codes must be indicated in Form Locator 80. The description is not required, nor is the policyholder, plan name, group number, etc.
| Code | Description |
| OI-P | PAID in part or in full by commercial health insurance or commercial HMO. In Form Locator 54 of this claim form, indicate the amount paid by commercial health insurance to the provider or to the insured. |
| OI-D | DENIED by commercial health insurance or commercial HMO following submission of a correct and complete claim, or payment was applied towards the coinsurance and deductible. Do not use this code unless the claim was actually billed to the commercial health insurer. |
| OI-Y | YES, the member has commercial health insurance
or commercial HMO coverage, but it was not billed for reasons including, but
not limited to the following:
|
| Note: | The provider may not use OI-D or OI-Y if the member is covered by a commercial HMO and the HMO denied payment because an otherwise covered service was not rendered by a designated provider. Services covered by a commercial HMO are not reimbursable by ForwardHealth except for the copayment and deductible amounts. Providers who receive a capitation payment from the commercial HMO may not submit claims to ForwardHealth for services that are included in the capitation payment. |
Form Locator 81 a-d — CC
If the billing provider's NPI is indicated in Form Locator 56, enter the
qualifier "B3" in the first field to the right of the form locator, followed by
the 10-digit provider taxonomy code in the second field.