A Guide To Using The CMS-1500 and UB-04 Forms

StrataPT,

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Article Summary

  1. This is the standard health insurance claim form used for submitting physician and professional claims to bill Medicare providers.
  2. The AHA (American Hospital Association) and the NUBC (National Uniform Billing Committee) oversee and monitor the use of the UB-04 to ensure it is up-to-date and equally useful for patients, medical providers, and insurance companies.
  3. The UB-04 is the claim form for institutional facilities and includes the following: The form would be used for surgery, radiology, laboratory, or other facility services.
  4. Both the CMS-1500 and UB-04 forms contain many of the same boxes that need to be filled out including patient demographics, provider identification information, procedures and charges, and insurance plan identification information.
  5. While both the CMS-1500 and UB-04 forms help to process the medical claim of a patient, the insurance company is reimbursing the services and they will reject the claim if it doesn’t meet their criteria.

What is the difference between the CMS-1500 and UB-04 forms? That is a question that seems to get tossed around a lot, so in this guide, we’ll break down each form to determine how and when each should be used. For more information about billing processes, please read the Billing Guide for Physical therapists.

While the CMS-1500 and UB-04 forms may look similar, they are very different and have distinct purposes. Thus, the two forms cannot be used interchangeably. First, let’s look at the individual forms and see why they are different in their functions.

CMS-1500 Form (sometimes called HCFA 1500):

This is the standard health insurance claim form used for submitting physician and professional claims to bill Medicare providers. In other words, the CMS-1500 is used for individual provider claims and is used to submit charges under Medicare Part-B.

Filing Claims Using the CMS Form

Understanding CMS-1500's definition ensures physicians and healthcare professionals use the CMS-1500 form to file medical claims accurately.  Form CMS-1500 is a paper claim form that health care providers use to bill carriers of Medicare.

Most paper claims that are submitted to Medicare are read via Optical Character Recognition (OCR) technology, so you’ll need to fill out the form in red ink. You’ll also need to be sure that you’ve thoroughly completed every necessary section of the form prior to submitting it.

Before You Submit a Claim

Physicians can submit the CMS-1500 form electronically, although paper claims are still in use. The payment will depend on different factors, including the patient's condition, the network status between the client and the patient and any previous settings. 

Completing a CMS Claim Form

A CMS-1500 claim form has approximately 33 fields that gather information about the patient, professional, and the treatment process. Every claim form needs to be duly completed for the payer to process the payments. Therefore, healthcare professionals should consult with the payer to understand the billing procedures. 

Electronic Claims

To use electronic claims, both parties must agree on the billing process. Some payers will need a prior third-party agreement before processing the claims. The transactions should meet the EDI requirements. Unique electronic filing codes will minimize mistakes in the claims process. 

UB-04 (also known as the CMS-1450):

As of 2007, the UB-04 replaced the UB-92. The AHA (American Hospital Association) and the NUBC (National Uniform Billing Committee) oversee and monitor the use of the UB-04 to ensure it is up-to-date and equally useful for patients, medical providers and insurance companies. The UB-04 is the claim form for institutional facilities, and includes the following:

  • Hospitals
  • Rehab facilities, e.g. physical therapy, occupational therapy and speech therapy
  • General health centers, federal health centers and rural clinics
  • Specialized health centers, e.g. mental health, renal health and rehabilitation clinics
  • Hospices

The form would be used for surgery, radiology, laboratory, or other facility services. This form is used to submit charges under Medicare Part-A.

Who Can Bill Claims Using the UB?

All institutional providers may use the UB-04 form to bill claims, such as hospitals, specialists, mental health centers, hospices, rehabs, organ procurement organizations and therapy services. 

Tips for Preparing the UB

The UB form can be cumbersome. Here are some tips to consider:

  • Ensure you get accurate payer’s information and instructions
  • Match the insurance card information to the form
  • Use the NPI correctly when needed
  • Use the correct diagnosis and procedure codes (modifiers acceptable as needed) 
  • Enter only the service facility or institution’s physical address for the location field

Things to Consider When Filing Claim Forms

There are multiple things to keep in mind when filing a claim form. Notably:

  • Ensure the forms are legible and correctly aligned and use black ink, as the OCR will drop anything in red ink.
  • Insurance companies scan the forms with Optical Character Recognition (OCR) to analyze the data and process your payment. 
  • A UB-04 has 81 fields, while CMS-1500 has 33 fields. 
  • Following each insurance company's requirements will result in a smoother claims process.

What are the differences?

One will quickly notice that the UB-04 form has more than twice the amount of fields than the CMS-1500. This is because hospital billing has many more codes and services in their complex system.

Even though the UB-04 is used to submit charges for Part-A providers, those same providers can still use the UB-04 to bill for Part-B services. This would be most common for institutional facilities such as licensed rehab facilities and SNF’s. The distinction is inpatient (UB-04) and outpatient (CMS 1500 or UB-04 if provided under an institutional license).

Both the CMS-1500 and UB-04 forms contain many of the same boxes that need to be filled out including patient demographics, provider identification information, procedures and charges and insurance plan identification information. The more information you can provide to the patient’s insurance company, the better. It is important to include information like when the first occurrence began, is it recurring or onset, if it was related to an accident, etc. Also, always be sure to recheck all claims for coding accuracy.

Unfortunately, there still may be gray areas as to which form is required. While both the CMS-1500 and UB-04 forms help to process the medical claim of a patient, the insurance company is reimbursing the services and they will reject the claim if it doesn’t meet their criteria. If you still have questions about these forms, the friendly representatives at StrataPT can help. Backed by our 100% US-based customer support, we are the leading business operating system for PT/OT practices in the US and offer exclusive solutions centered around ease of onboarding, revenue cycle management and transparent patient reporting.

Contact us today or schedule a free demo with one of our team members.

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