The UB-04 Claim Form

1. PART TWO The UB-04 Claim Form Chapter 7 Provider Information

2. LEARNING OUTCOMES After completing this chapter, you will be able to define the key terms and: Identify the types of provider information that belong in the first seven fields (FLs 1-7) of the UB-04 claim form. Understand the different formats that are required for specific form locators. Explain the difference between the patient control number (FL 3a) and the patient’s medical record number (FL 3b). Discuss the appropriate use of four-digit codes in FL 4 to indicate the type of bill (TOB) being generated.

3. LEARNING OUTCOMES (cont.) Recognize which form locators contain data that necessitate data entry in other fields or data that must be coordinated with the data supplied in other fields. Understand the importance of the from and through dates in FL 6 (Statement Covers Period), and know how to report the correct dates for different types of claims.

4. KEY TERMS • comprehensive outpatient rehabilitation facility (CORF) • continuing claim • critical access hospital (CAH) • interim bill • medical/health record number • patient control number • statement covers period • swing bed hospital • type of bill (TOB)

5. FL 1 PROVIDER NAME, ADDRESS, AND TELEPHONE NUMBER • FL 1 contains the name and service location of the provider submitting the claim • Guidelines • Completion of this field is required for Medicare and all other payers • Minimum entry: provider’s name, city, state, zip code • Punctuation may be used in this field

6. FL 2 PAY-TO NAME AND ADDRESS • FL 2 is used only if the address that payment is to be mailed to is different than the address in FL 1. • Guidelines • Up to three lines of text are allowed • Line 4 is reserved for assignment by the NUBC and should be left blank

7. FL 3a PATIENT CONTROL NUMBER • The patient control number is a unique alphanumeric identifier assigned by the provider • Main purpose is to identify payments from payers • Usually associated with a single episode of care and used to locate patient’s financial records to post payments • Guidelines • Completion required for Medicare and all other payers • Limited to 20 alphanumeric characters by HIPAA (no spaces or special characters allowed) • FL 3b MEDICAL RECORD NUMBER • The medical record number is assigned by the provider to track a patient’s medical history across multiple episodes of care • Guidelines • Unique alphanumeric identifier containing up to 24 characters

8. FL 4 TYPE OF BILL • Type of bill (TOB) is a 4-digit code consisting of a leading zero followed by three digits that have specific meanings: • second digit identifies the type of facility • third digit classifies the type of care • fourth digit, frequency code, indicates sequence of the bill within a given episode of care • Guidelines • Completion required by Medicare and all other payers • First component (2nd and 3rd digits) = bill type • Second component (4th digit) = frequency code

9. FL 4 TYPE OF BILL (cont.) • Second Digit – Type of Facility • CodeType of Facility • 1 Hospital • 2 Skilled nursing facility (SNF) • 3 Home health facility • 4 Religious nonmedical health care institution – hospital • 5 Reserved for national assignment • 6 Intermediate care facility • 7 Clinic or hospital-based renal dialysis facility • 8 Special facility or hospital ambulatory surgical center • 9 Reserved for national assignment

10. FL 4 TYPE OF BILL (cont.) • Third-Digit Bill Classification (except clinics and special facilities) • CodeBill Classification • 1 Inpatient (including Medicare Part A) • 2 Inpatient (Medicare Part B only) including home health visits under Part B plan of treatment • 3 Outpatient including home health visits under Part A plan of treatment • 4 Other (Medicare Part B) including home health and other medical services not under a plan of treatment • 5 Intermediate care – level I • 6 Intermediate care – level II • 7 Reserved for national assignment • 8 Swing bed • 9 Reserved for national assignment

11. FL 4 TYPE OF BILL (cont.) • Third-Digit Bill Classification – Clinics only • CodeClinic Type • 1 Rural health clinic (RHC) • 2 Hospital-based or independent renal dialysis facility • 3 Freestanding provider-based federally qualified health center (FQHC) • 4 Outpatient rehabilitation facility (ORF) • 5 Comprehensive outpatient rehabilitation facility (CORF) • 6 Community mental health center (CMHC) • 7 Reserved for national assignment • 8 Reserved for national assignment • 9 Other

12. FL 4 TYPE OF BILL (cont.) • Third-Digit Bill Classification – Special Facilities only • CodeSpecial Facility Type • 1 Hospice (non-hospital-based) • 2 Hospice (hospital-based) • 3 Ambulatory surgical center services to hospital outpatients • 4 Freestanding birthing center • 5 Critical access hospital (CAH) • 6 Residential facility (Not used for Medicare) • 7 Reserved for national assignment • 8 Reserved for national assignment • 9 Other

13. Relating the Third-Digit Bill Classification to the Revenue Code • The third-digit bill classification codes are often the main indicators of the type of revenue codes required in FL 42 (Revenue Code) • For example: • In TOB 011X, the third-digit code 1 (inpatient) indicates that a revenue code for some type of room and board charge is required in FL 42 • In TOB 013X, the third-digit code 3 (outpatient) indicates that a room and board charge cannot appear in FL 42

14. FL 4 TYPE OF BILL (cont.) • Fourth Digit – Frequency of the Bill • CodeFrequency • 0 Nonpayment/Zero Claim • 1 Admit Through Discharge Claim • 2 Interim – First Claim • 3 Interim – Continuing Claim (Not Valid for IP Hospital PPS Bills) • 4 Interim – Last Claim (Not Valid for IP Hospital PPS Bills) • 5 Late Charge(s) Only Claim • 6 Unassigned • 7 Replacement of Prior Claim • 8 Void/Cancel of a Prior Claim • 9 Final Claim for a Home Health PPS Episode

15. FL 5 FEDERAL TAX NUMBER • Federal tax number is also known as TIN (tax identification number) or EIN (employer identification number) • Federal tax number is reported on bottom line of FL 5 • Top line of FL 5 can be used for an affiliated subsidiary • Guidelines • Completion required for Medicare and most other payers • 10 character alphanumeric field allows for nine digits and a hyphen (hyphen may be eliminated) • Example: 92-3760176 or 923760176

16. FL 6 STATEMENT COVERS PERIOD(FROM – THROUGH) • FL 6 reports the dates that represent the beginning and ending dates of service for the full period included on the bill. • Guidelines • Completion required by all payers • Dates must be reported in six-digit MMDDYY format (no hyphens or slashes) • The admission date should not be confused with the from date in this field; these dates may or may not be the same • For same-day services, the from and through dates must be identical • FL 7 UNLABELED FIELD(reserved for national assignment)

17. CHAPTER REVIEW • Does FL 2 have to be completed if payment is being mailed to the same address reported in FL 1? • [no] • What is the major difference between FL 3a (Patient Control Number) and FL 3b (Medical Record Number)? • [patient control number is used for a single episode of care while the medical record number spans multiple episodes of care] • What information is identified by the second, third, and fourth digits of the Type of Bill (TOB) code entered in FL 4? • [second digit = type of facility,third digit = bill classification,fourth digit = frequency of bill]

18. TERMINOLOGY QUIZ • CORF is an abbreviation for: • [Comprehensive Outpatient Rehabilitation Facility] • What is a swing bed? • [a hospital bed used to provide acute care as well as long-term care services; when needed, the bed “swings” from providing acute care to providing long-term care; a hospital with a Medicare-approved swing bed agreement is a “swing bed hospital”] • What is a critical access hospital (CAH)? • [freestanding hospital emergency department that provides outpatient care as well as limited inpatient care when necessary to stabilize a patient before transfer or discharge] • A bill that does not cover a complete hospital stay is an: • [interim bill]