Institutional claims submitted to BCBST must be filed on the CMS-1450 (UB-04) or its electronic equivalent.
The UB-04 contains a number of improvements and enhancements that include better alignment with the electronic HIPAA ASC X 12N 837-Institutional Transaction Standard. The UB-04 paper billing form accommodates the reporting of the National Provider Identifier
(NPI) Number. The NPI is a single Provider identifier, replacing the different Provider identifiers health care systems previously used for each health plan with which you do business. The NPI Identifier, which implements a requirement of Health Insurance Portability and Accountability Act of 1996 (HIPAA), must be used by all HIPAA covered entities, which are health plans, health care clearinghouses, and health care Providers.
Note: BCBST follows CMS guidelines for filing the National Provider Identifier (NPI) Number. A sample copy and field description of the UB-04 claim form follows:
a. CMS-1450 (UB-04) Form Locators and Field Description:
Form Locator 1 Provider Name, Address, Telephone Number*** Form Locator 2 Pay-to Name, Address, City, State, and ID
Form Locator 3 3a>Patient Control Number*** 3b>Medical Record Number*** Form Locator 4 Type of Bill***
Form Locator 5 Federal Tax Number*** Form Locator 6 Statement Covers Period*** Form Locator 7 Unlabeled Field
Form Locator 8 8a>Patient Name-ID 8b>Patient Name***
Form Locator 9 9a>Patient Address-Street 9b>Patient Address-Other
9b>Patient Address-City 9c>Patient Address-State 9d>Patient Address-Zip 9e>Patient Address-Country Code***
Form Locator 10 Patient Birthdate*** Form Locator 11 Patient Sex***
Form Locator 12 Admission Date*** (Inpatient)
Form Locator 13 Admission Hour*** (except for Bill Type 02X) Form Locator 14 Type of Admission/Visit***
Form Locator 15 Source of Admission***
Form Locator 16 Discharge Hour*** (final inpatient claim only) Form Locator 17 Patient Discharge Status***
Form Locator 18 Condition Codes Form Locator 19 Condition Codes Form Locator 20 Condition Codes Form Locator 21 Condition Codes Form Locator 22 Condition Codes Form Locator 23 Condition Codes Form Locator 24-28 Condition Codes Form Locator 29 Accident State Form Locator 30 Unlabeled Field
Form Locator 31 a-b Occurrence Code/Date Form Locator 32-34 a-b Occurrence Codes and Dates
Form Locator 35 a-b Occurrence Span Code/From//Through Form Locator 36 a-b Occurrence Span Code/From/Through Form Locator 37 a-b Unlabeled Fields
Form Locator 38 1-5 Responsible Party Name/Address Form Locator 39 a-d Value Code-Code
Form Locator 39 a-d Value Code-Amount Form Locator 40 a-d Value Code-Code Form Locator 40 a-d Value Code –Amount Form Locator 41 a-d Value Code-Code Form Locator 41 a-d lines Value Code-Amount Form Locator 42 Revenue Code***
Form Locator 43 1-22 Revenue Code Description*** Form Locator 43-44 Line 23 Page_of_Creation_Date Form Locator 44 HCPCS/Rates/HIPPS/Rate Codes*** Form Locator 45 1-22 Service Date
Form Locator 45 Line 23 Creation Date Form Locator 46 Units of Service*** Form Locator 47 Total Charges*** Form Locator 48 Non-Covered Charges Form Locator 49 Unlabeled Field Form Locator 50 Payer Identification*** Form Locator 51 Health Plan ID
a. CMS-1450 (UB-04) Form Locators and Field Description (cont’d): Form Locator 52 Release of Information Certification Indicator Form Locator 53 Assignment of Benefits Certification Indicator Form Locator 54 Prior Payments -- Payer
Form Locator 55 Estimated Amount Due Form Locator 56 NPI
Form Locator 57 Other Provider ID-Primary/Secondary*** Form Locator 58 Insured's Name***
Form Locator 59 Patient’s Relationship to Insured
Form Locator 60 Certificate/Social Security Number/Health Insurance Claim/Identification Number***
Form Locator 61 Insured Group Name Form Locator 62 Insurance Group Number Form Locator 63 Primary/Secondary/Third Form Locator 64 Document Control Number Form Locator 65 Employer Name
Form Locator 66 DX Version Qualifier Form Locator 67 Principal Diagnosis Code*** Form Locator 67 A-Q Other Diagnosis Codes Form Locator 68 Unlabeled Field
Form Locator 69 Admitting Diagnosis Code*** (Inpatient) Form Locator 70 Patient’s Reason for Visit Code
Form Locator 71 PPS Code*** (if in Provider contract with payor) Form Locator 72 A-C External Cause of Injury Code
Form Locator 73 Unlabeled
Form Locator 74 ICD-9 Code/Date*** (if surgical procedure performed) Form Locator 74 a-e Other Procedure Code/Date
Form Locator 75 Unlabeled Field
Form Locator 76 1- Attending –NPI/QUAL/ID Form Locator 76 2-Attending-Last/First Form Locator 77 1-Operating-NPI/QUAL/ID Form Locator 77 2-Operating-Last/First Form Locator 78 1-Other ID-QUAL/NPI/ID Form Locator 78 2-Other ID-Last/First
Form Locator 79 1-Other ID- QUAL/NPI/QUAL/ID Form Locator 79 2-Other ID-Last/First
Form Locator 80 1-4 Remarks
Form Locator 81 a-d Code-Code-QUAL/CODE/VALUE ** Required Fields by Pre Adjudication Edits
*** Required Fields by BCBST Electronic Billing
As a reminder, to ensure compliance with National Uniform Billing Committee (NUBC) guidelines, claims submitted on or after 10/1/2012 with a discharge status 20, 40, 41, or 42 must also include an
b. Revenue Code (FL42)
Complete this field with the revenue code related to the services that are being billed to BCBST. For specific instructions regarding each revenue code, refer to the billing guidelines defined below:
Billing Guidelines (Form Locator 42) Field Definitions
Each field contains specific billing information critical to understanding how to file a claim with BCBST. By following these guidelines the facility will maximize
reimbursement.
Revenue Code – The Revenue Code is the initial indicator to the claims
administration system as to what type of services were performed. Revenue Codes for inpatient and outpatient services are included in the billing guidelines.
Category – The Category defines a general description of the type of service provided under the Revenue Code. Some Revenue Codes fall into several Categories such as Revenue Code 110. Revenue Code 110 is generally used to file services under Medical, Surgical, Orthopedic, Trauma, Trauma Medical and Trauma Surgical, among others. The participating Provider Contract outlines which Revenue Codes can be filed under each Category.
Reimbursement Rule - The Reimbursement Rule explains what type of
reimbursement the facility should expect if billed properly. It is extremely important to have the facility’s contract on hand when reviewing how a claim should be reimbursed. BCBST claims administration system in some cases will default to another Category in the event that there is no specifically contracted rate for a service. In addition, some services are ineligible as “Not Medically Necessary,” or there is no negotiated fee.
Principal Diagnosis - The Principal Diagnosis determines the Category for
reimbursement. The Principal Diagnosis should always be billed in Form Locator 67 on the CMS-1450 claim form. This field indicates to our system the primary reason for the services rendered to the patient.
Principal Procedure Code – The Principal Procedure Code is an ICD-9 Procedure Code. This code will help determine the Category of service. The facility should bill the correct Principal Procedure Code in Form Locator 74 of the CMS-1450.
CPT®/HCPCS Required –CPT® Codes should always be billed on the CMS-1450 in Form Locator 44. This field indicates when a Revenue Code must be filed with a CPT®/HCPCS Code. If a required CPT® /HCPCS Code is missing, the claim may be denied and returned to the facility for proper coding.
Note: Billing outpatient procedures using CPT®/HCPCS Codes on the CMS-1450 is a new requirement for BCBST. However, Medicare already requires this information.
c. HCPCS Codes/Rates (FL44)
Complete this field with the CPT®/HCPCS Code related to the service being provided. To determine which CPT®/HCPCS Codes are to be filed with a related Revenue Code, refer to the FL44 – BCBST CPT®/HCPCS Code Requirement.
Note: For the related contract, BCBST accepts only valid CPT®/HCPCS Codes that can be billed in a hospital acute care setting. Prior to payment, unlisted procedures must be filed hard copy with the supporting medical record.
Billing Guidelines (Form Locator 44) Field Definitions
Each field contains specific billing information critical to understanding how to file a claim with BCBST. By following these guidelines, the facility will maximize
reimbursement. These guidelines only apply to Revenue Codes stated in the Billing Guidelines (Form Locator 42) as requiring a CPT®/HCPCS Code.
CPT®– The CPT®Field lists the CPT®/HCPCS Code or Range of Codes eligible to be filed in Form Locator 44 of the CMS-1450.
- Codes ranging from 10000-69999 are generally surgical codes and require individual negotiated rates for outpatient services. Please refer to the correct Network Attachment for reimbursement schedules.
- Codes ranging from 70000-79999 are generally radiology codes. Please refer to the Provider Network Attachment for any Procedure Codes that have individual negotiated rates.
- Codes ranging from 80000-89999 are generally laboratory or pathology codes. Please refer to your Provider Network Attachment for any Procedure Codes that have individual negotiated rates.
MOD – The Modifier (MOD) Field states any code that must be filed with a modifier in addition to a CPT®/HCPCS Code.
Required Revenue Code(s) - The Required Revenue Code(s) Field is provided so the facility will know exactly what Revenue Codes are eligible to bill BCBST for each CPT®/HCPCS Code. Without the correct Revenue Code and CPT®/HCPCS Codes, BCBST will not accept the claim for consideration of benefits. Incorrectly filed claims may be returned to the Provider for correction.
Billing Instructions – The Billing Instruction Field explains the requirements to bill the selected CPT®/HCPCS Code. This field also provides an insight as to how BCBST adjudicates the claim.
d. Service Units (FL46)
In general, report the quantitative measure of service, by revenue category, to or for the patient; such as, the number of accommodation days, visits, miles, pints of blood, units or treatments. Units for related CPT®/HCPCS Codes are to be based on the number of times the service or procedure was performed, as defined by the CPT®/HCPCS Code. Visit codes are not to be reported as units.
e. Principal Diagnosis Code (FL67)
Depending on your contract, the Principal Diagnosis Code may be required for proper adjudication of an inpatient claim. For specific instructions, see Billing Guidelines (Form Locator 42). If applicable, report the full ICD-9 CM Code that describes the principal diagnosis.
f. Principal Procedure Code and Date (FL74)
Depending on your contract, the Principal Procedure Code may be required for proper adjudication of an inpatient claim. For specific instructions refer to Billing Guidelines (Form Locator 42). If applicable, report the ICD-9-CM Code for the principal procedure performed during the period covered by the bill and the date that the principal procedure was performed.
g. Attending Physician (FL76)
Report the name and UPIN Number of the licensed Physician who is expected to certify the Medical Necessity of the services rendered and who is primarily responsible for the patient’s care. (If UPIN is NOT available, enter “OTH000” in this field.
h. CMS-1450 Specific
All date information should be shown in the following format (except Form Locator 10 –Birth Date): MMDDYY MM=month (01-12) DD=day (01-31) YY=year (00-99) Example: January 1, 2004 = 010404
Form Locator 10 must be a continuous 8-digit number (Correct: January 1, 2004 = 01042004)
Do not exclude leading zeros in the date fields; Multi-page Claims:
All diagnosis code(s) listed on first page must be listed on each page.
Place the total amount and 0001 Total Revenue Code only on the last page of the claim. The 0001 Total Revenue Code line on the last page of the claim should reflect the sum of the line items for all pages.
Use the words “Continued on next page” or “Page X of X” on line 23 on each page (except on the last page, which reflects the total charge on the 0001 Total Revenue Code line).
Staple only the pages of the individual claim together as one. Do not staple several multi-page claims together as one.
Donor/Recipient information when filing transplant claims:
Block 2 should contain the name of patient that received the service. “In this case it will be the Donor”.
Block 19 should be marked “Donor” and contain the “Recipient’s” name. Effective Aug. 1, 2012, BCBST will update OCR scanning processes for CMS-1500 and CMS-1450 paper claims. Following the 2012 OfficialUB-04 Data Specifications Manual guidelines, this update will not require any changes related to the CMS-1500, however the following changes will be required when submitting CMS-1450 paper claims: Form Locator 12 - Admit Date: Admit date should only be populated for inpatient,
home health, and hospice claims. A rejection will occur for any other claim type. Form Locator 13 - Admit Hour: Admit hour should only be populated for inpatient
claims, excluding type of bill 021x. A rejection will occur for any other claim type. Form Locator 15 - Admission Source: Admission source should be populated for
ALL institutional claims except those with a TOB 014X. Any UB-04 (or its successor) claim form submitted without an Admission Source will be rejected and returned for correction.
Form Locator 69 - Admitting Diagnosis Code: Admitting diagnosis code is only required for inpatient claims. A rejection will occur for any other claim type.
Form Locator 74 - Principal Procedure Code: Principal procedure code should only be submitted for inpatient claims. A rejection will occur for any other claim type. Form Locator 74a-e - Other Procedure Code: Other procedure codes should only
be submitted for inpatient claims. A rejection will occur for any other claim type. Note: Effective with date of service 4/01/08 and after, the NDC requirements must also be fulfilled by facilities filing Outpatient UB claims on a CMS-1450 claim form or
submitted electronically in the ANSI-837 Institutional version format. NDC information is not required on Inpatient UB claims. When an NDC code is required, all of the following NEW data elements are required, in addition to the HCPCS/ CPT® code. Any missing element may result in the claim being returned unprocessed.
Element Description
1. NDC Qualifier N4
2. NDC Number Eleven digit number
3. NDC Quantity Qualifier F2 - International Unit
GR – Gram ME - Milligram ML - Milliliter UN - Unit
4. NDC Quantity Numeric value
5. NDC Unit Price (ANSI-837 only)
As a reminder, to ensure compliance with National Uniform Billing Committee (NUBC) guidelines, claims submitted on or after 10/1/2012 with a discharge status 20, 40, 41, or 42 must also include an Occurrence Code 55 and date of death.
NUBC is responsible for the design and printing of the UB-04. Additional information for the UB-04 is available to subscribers. If you are interested in additional information please visit the NUBC website at www.nubc.org.