CMS-1450 (UB-04).Supporting Statement

Supporting Statement and Supporting Regulations Contained in 42 CFR 424.5 for the Uniform Institutional Providers Form -- CMS-1450 (UB-04)

A. Background

There are new data element changes to the UB-04 CMS-1450 data set. All hardcopy claims processed by Medicare fiscal intermediaries must be submitted on the UB-04 CMS-1450 after May 23, 2007. Data fields in the X12N 837 data set are consistent with the UB-04 CMS-1450 data set.

We are requesting approval under a new OMB approval number replacing the UB-92 number 0938-0279.

CMS is requesting Office of Management and Budget (OMB) approval of the CMS-1450 (UB-04 - attachment 1) Uniform Institutional Provider Claim Form (previously the UB-92 – attachment 2). The requirements associated with the Medicaid burden are included in the package which was approved under OMB control # 0938-0279 with an expiration date 11/2008 for the UB-92 renewal.

B. Justification

1. Need and Legal Basis

The basic authorities which allow providers of service to bill for services on behalf of the beneficiary are section 1812 (42 USC 1395d - http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=browse_usc&docid=Cite:+42USC1395d) (a) (1), (2), (3), and (4) and 1833 (2) (B) of the Social Security Act). Also, section 1835 (42 USC 1395n) requires that payment for services furnished to an individual may be made to providers of services only when a written request for payment is filed in such form as the Secretary may prescribe by regulations. Section 42 CFR 424.5(a)(5) requires providers of services to submit a claim for payment prior to any Medicare reimbursement. Charges billed are coded by revenue codes. The bill specifies diagnoses according to the International Classification of Diseases, Ninth Edition (ICD-9-CM) code. Inpatient procedures are identified by ICD-9-CM codes, and outpatient procedures are described using the CMS Common Procedure Coding System (HCPCS). These are standard systems of identification for all major health insurance claims payers. Submission of information on the CMS-1450 permits Medicare intermediaries to receive consistent data for proper payment.

2. Information Users

The UB-92 is managed by the NUBC, sponsored by the American Hospital Association. Most payers are represented on this body, and the UB-92 is widely used in the industry. The UB-04 is based on of the UB-92 with a similar look.

Medicare receives 98.8 percent of the CMS-1450s submitted by institutional providers electronically. Because of the number of small and rural providers who do not submit claims electronically, it is not possible to achieve total electronic submission at this time. Intermediaries use the information on the CMS-1450 to determine whether to make Medicare payment for the services provided, the payment amount, and whether or not to apply deductibles to the claim. The same method is also used by other payers.

CMS is also a secondary user of data. CMS uses the information to develop a data base which is used to update and revise established payment schedules and other payment rates for covered services. CMS also uses the information to conduct studies and reports.

UB-92 to UB-04 mapping

							* FL68,75,80 Size Updated 6/21/05
	UB-92					UB-04	** FL07, 30 Size Updated 12/15/05
										Buffer
FL	Description	Line	Type	Size	FL	Description	Line	Type	Size	Space Notes
F FL01	Provider Name	1	AN	25	FL01	Provider Name	1	AN	25
FL01	Provider Street Address	2	AN	25	FL01	Provider Street Address	2	AN	25
FL01	Provider City, State, Zip	3	AN	25	FL01	Provider City, State, Zip	3	AN	25
FL01	Provider Telephone, Fax, Country Code	4	AN	25	FL01	Provider Telephone, Fax, Country Code	4	AN	25
FL02	Unlabeled Fields	1	AN	20	FL02	Pay-to Name	1	AN	25	New
FL02	Unlabeled Fields	2	AN	30	FL02	Pay-to Address	2	AN	25	New
					FL02	Pay-to City, State	3	AN	25	New
					FL02	Pay-to ID	4	AN	25	New
FL03	Patient Control Number	1	AN	20	FL03a Patient Control Number			AN	24
					FL03b Medical Record Number			AN	24	Moved/New
FL04	Type of Bill	1	AN	3	FL04	Type of Bill	1	AN	4	1 Expanded
FL05	Federal Tax Number	1	AN	4	FL05	Federal Tax Number	1	AN	4
FL05	Federal Tax Number	2	AN	10	FL05	Federal Tax Number	2	AN	10
FL06	Statement Covers Period - From/Through	1	N/N	6/6	FL06	Statement Covers Period - From/Through	1	N/N	6/6	1/1
					FL07	Unlabeled	1	AN	7**
							2	AN	8**
FL07	Covered Days	1	N	3		Eliminated - Substitute new Value Code
FL08	Non-covered Days	1	N	4		Eliminated - Substitute new Value Code
FL09	Coinsurance Days	1	N	3		Eliminated - Substitute new Value Code
FL10	Lifetime Reserve Days	1	N	3		Eliminated - Substitute new Value Code
FL11	Unlabeled	1		12		Eliminated
FL11	Unlabeled	2		13		Eliminated
FL12	Patient Name	1	AN	30	FL08	Patient Name - ID	1a	AN	19	New
					FL08	Patient Name	2b	AN	29
FL13	Patient Address	1	AN	50	FL09	Patient Address - Street	1a	AN	40	1 Discrete
					FL09	Patient Address - City	2b	AN	30	2 Discrete
					FL09	Patient Address - State	2c	AN	2	1 Discrete
					FL09	Patient Address - ZIP	2d	AN	9	1 Discrete
					FL09	Patient Address - Country Code	2e	AN	3	Discrete
FL14	Patient Birthdate	1	N	8	FL10	Patient Birthdate	1	N	8	1
FL15	Patient Sex	1	AN	1	FL11	Patient Sex	1	AN	1	2
FL16	Patient Marital Status	1	AN	1		Eliminated
FL17	Admission Date	1	N	6	FL12	Admission Date	1	N	6
FL18	Admission Hour	1	AN	2	FL13	Admission Hour	1	AN	2	1
FL19	Type of Admission/Visit	1	AN	1	FL14	Type of Admission/Visit	1	AN	1	2
FL20	Source of Admission	1	AN	1	FL15	Source of Admission	1	AN	1	1
FL21	Discharge Hour	1	AN	2	FL16	Discharge Hour	1	AN	2	2
FL22	Patient Status/Discharge Code	1	AN	2	FL17	Patient Discharge Status	1	AN	2	2
FL23	Medical/Health Record Number		AN	17		Moved to FL3b
FL24	Condition Codes		AN	2	FL18	Condition Codes		AN	2	1
FL25	Condition Codes		AN	2	FL19	Condition Codes		AN	2	1
					FL20	Condition Codes		AN	2	1

								* FL68,75,80 Size Updated 6/21/05
	UB-92					UB-04		** FL07, 30 Size Updated 12/15/05
										Buffer
FL	Description	Line	Type	Size	FL	Description	Line	Type	Size	Space Notes
FL26	Condition Codes		AN	2	FL21	Condition Codes		AN	2	1
					FL22	Condition Codes		AN	2	1
FL27	Condition Codes		AN	2	FL23	Condition Codes		AN	2	1
					FL24	Condition Codes		AN	2	1
FL28	Condition Codes		AN	2	FL25	Condition Codes		AN	2	1
					FL26	Condition Codes		AN	2	1 New
FL29	Condition Codes		AN	2	FL27	Condition Codes		AN	2	1 New
					FL28	Condition Codes		AN	2	1 New
FL30	Condition Codes		AN	2
					FL29	Accident State	1	AN	2	1 New
					FL30	Unlabeled	1	AN	12	** No "Xs" on proof
					FL30	Unlabeled	2	AN	13
FL31	Unlabeled	1		5
FL31	Unlabeled	2		6
FL32	Occurrence Code/Date	a	AN/N	2/6	FL31	Occurrence Code/Date	a	AN/N	2/6	1/1
FL32	Occurrence Code/Date	b	AN/N	2/6	FL31	Occurrence Code/Date	b	AN/N	2/6	1/1
FL33	Occurrence Code/Date	a	AN	2/6	FL32	Occurrence Code/Date	a	AN/N	2/6	1/1
FL33	Occurrence Code/Date	b	AN/N	2/6	FL32	Occurrence Code/Date	b	AN/N	2/6	1/1
FL34	Occurrence Code/Date	a	AN	2/6	FL33	Occurrence Code/Date	a	AN/N	2/6	1/1
FL34	Occurrence Code/Date	b	AN/N	2/6	FL33	Occurrence Code/Date	b	AN/N	2/6	1/1
FL35	Occurrence Code/Date	a	AN	2/6	FL34	Occurrence Code/Date	a	AN/N	2/6	1/1
FL35	Occurrence Code/Date	b	AN/N	2/6	FL34	Occurrence Code/Date	b	AN/N	2/6	1/1
FL36	Occurrence Span Code/From/Through	a	AN/N/N	2/6/6	FL35	Occurrence Span Code/From/Through	a	AN/N/N	2/6/6	1/1/1
FL36	Occurrence Span Code/From/Through	b	AN/N/N	2/6/6	FL35	Occurrence Span Code/From/Through	b	AN/N/N	2/6/6	1/1/1
					FL36	Occurrence Span Code/From/Through	a	AN/N/N	2/6/6	1/1/1 New
					FL36	Occurrence Span Code/From/Through	b	AN/N/N	2/6/6	1/1/1 New
					FL37	Unlabeled	a	AN	8
					FL37	Unlabeled	b	AN	8
FL37	ICN/DCN	A	AN	23		Moved to FL64				Relocated
FL37	ICN/DCN	B	AN	23		Moved to FL64
FL37	ICN/DCN	C	AN	23		Moved to FL64
FL38	Responsible Party Name/Address	1	AN	40	FL38	Responsible Party Name/Address	1	AN	40	2
FL38	Responsible Party Name/Address	2	AN	40	FL38	Responsible Party Name/Address	2	AN	40	2
FL38	Responsible Party Name/Address	3	AN	40	FL38	Responsible Party Name/Address	3	AN	40	2
FL38	Responsible Party Name/Address	4	AN	40	FL38	Responsible Party Name/Address	4	AN	40	2
FL38	Responsible Party Name/Address	5	AN	40	FL38	Responsible Party Name/Address	5	AN	40	2
FL39	Value Code - Code	a	AN	2	FL39	Value Code - Code	a	AN	2	1
FL39	Value Code - Amount	a	N	9	FL39	Value Code - Amount	a	N	9	1
FL39	Value Code - Code	b	AN	2	FL39	Value Code - Code	b	AN	2	1
FL39	Value Code - Amount	b	N	9	FL39	Value Code - Amount	b	N	9	1
FL39	Value Code - Code	c	AN	2	FL39	Value Code - Code	c	AN	2	1
FL39	Value Code - Amount	c	N	9	FL39	Value Code - Amount	c	N	9	1
FL39	Value Code - Code	d	AN	2	FL39	Value Code - Code	d	AN	2	1
FL39	Value Code - Amount	d	N	9	FL39	Value Code - Amount	d	N	9	1
FL40	Value Code - Code	a	AN	2	FL40	Value Code - Code	a	AN	2	1
FL40	Value Code - Amount	a	N	9	FL40	Value Code - Amount	a	N	9	1
FL40	Value Code - Code	b	AN	2	FL40	Value Code - Code	b	AN	2	1
FL40	Value Code - Amount	b	N	9	FL40	Value Code - Amount	b	N	9	1
FL40	Value Code - Code	c	AN	2	FL40	Value Code - Code	c	AN	2	1
FL40	Value Code - Amount	c	N	9	FL40	Value Code - Amount	c	N	9	1
FL40	Value Code - Code	d	AN	2	FL40	Value Code - Code	d	AN	2	1
FL40	Value Code - Amount	d	N	9	FL40	Value Code - Amount	d	N	9	1
FL41	Value Code - Code	a	AN	2	FL41	Value Code - Code	a	AN	2	1
FL41	Value Code - Amount	a	N	9	FL41	Value Code - Amount	a	N	9	1

								* FL68,75,80 Size Updated 6/21/05
	UB-92					UB-04		** FL07, 30 Size Updated 12/15/05
										Buffer
FL	Description	Line	Type	Size	FL	Description	Line	Type	Size	Space Notes
FL41	Value Code - Code	b	AN	2	FL41	Value Code - Code	b	AN	2	1
FL41	Value Code - Amount	b	N	9	FL41	Value Code - Amount	b	N	9	1
FL41	Value Code - Code	c	AN	2	FL41	Value Code - Code	c	AN	2	1
FL41	Value Code - Amount	c	N	9	FL41	Value Code - Amount	c	N	9	1
FL41	Value Code - Code	d	AN	2	FL41	Value Code - Code	d	AN	2	1
FL41	Value Code - Amount	d	N	9	FL41	Value Code - Amount	d	N	9	1
FL42	Revenue Code	1-23	N	4	FL42	Revenue Code	1-23	N	4	0.5
FL43	Revenue Code Description	1-23	AN	24	FL43	Revenue Code Description	1-22	AN	24	0.5
					FL43
					44	PAGE ___ OF ___ CREATION DATE	23	N/N	3/3	0.5 New
FL44	HCPCS/Rates/HIPPS Rate Codes	1-23 AN/N/AN		9	FL44	HCPCS/Rates/HIPPS Rate Codes	1-22 AN/N/AN		14	0.5 Expanded size
FL45	Service Date	1-23	N	6	FL45	Service Date	1-22	N	6	0.5
					FL45	Creation Date	23	N	6	0.5 New
FL46	Units of Service	1-23	N	7	FL46	Units of Service	1-22	N	7	0.5
										Removed
FL47	Total Charges	1-23	N	10	FL47	Total Charges	1-23	N	9	0.5 sign field
										Removed
FL48	Non-Covered Charges	1-23	N	10	FL48	Non-Covered Charges	1-23	N	9	0.5 sign field
FL49	Unlabeled	1-23	AN	4	FL49	Unlabeled	1-23	AN	2	0.5
FL50	Payer - Primary	A	AN	25	FL50	Payer Name - Primary	A	AN	23
FL50	Payer - Secondary	B	AN	25	FL50	Payer Name - Secondary	B	AN	23
FL50	Payer - Tertiary	C	AN	25	FL50	Payer Name - Tertiary	C	AN	23
FL51	Provider Number	A	AN	13	FL51	Health Plan ID	A	AN	15
FL51	Provider Number	B	AN	13	FL51	Health Plan ID	B	AN	15
FL51	Provider Number	C	AN	13	FL51	Health Plan ID	C	AN	15
FL52	Release of Information - Primary	A	AN	1	FL52	Release of Information - Primary	A	AN	1	1
FL52	Release of Information - Secondary	B	AN	1	FL52	Release of Information - Secondary	B	AN	1	1
Fl52	Release of Information - Tertiary	C	AN	1	FL52	Release of Information - Tertiary	C	AN	1	1
FL53	Assignment of Benefits - Primary	A	AN	1	FL53	Assignment of Benefits - Primary	A	AN	1	1
FL53	Assignment of Benefits - Secondary	B	AN	1	FL53	Assignment of Benefits - Secondary	B	AN	1	1
FL53	Assignment of Benefits - Tertiary	C	AN	1	FL53	Assignment of Benefits - Tertiary	C	AN	1	1
FL54	Prior Payments - Primary	A	N	10	FL54	Prior Payments - Primary	A	N	10	1
FL54	Prior Payments - Secondary	B	N	10	FL54	Prior Payments - Secondary	B	N	10	1
FL54	Prior Payments - Tertiary	C	N	10	FL54	Prior Payments - Tertiary	C	N	10	1
FL54	Prior Payments - Patient	4	N	10		Eliminated Patient Prior Payments
FL55	Estimated Amount Due - Primary	A	N	10	FL55	Estimated Amount Due - Primary	A	N	10	1
FL55	Estimated Amount Due - Secondary	B	N	10	FL55	Estimated Amount Due - Secondary	B	N	10	1
FL55	Estimated Amount Due - Tertiary	C	N	10	FL55	Estimated Amount Due - Tertiary	C	N	10	1
FL55	Estimated Amount Due - Patient	4	N	10		Eliminated Due from Patient
FL56	Unlabeled	1		13	FL56	NPI	1	AN	15
FL56	Unlabeled	2		14	FL57	Other Provider ID - Primary	A	AN	15
					FL57	Other Provider ID - Secondary	B	AN	15
					FL57	Other Provider ID - Tertiary	C	AN	15
FL57	Unlabeled	1		27		Deleted from UB-04
FL58	Insured’s Name - Primary	A	AN	25	FL58	Insured’s Name - Primary	A	AN	25	1
FL58	Insured's Name - Secondary	B	AN	25	FL58	Insured's Name - Secondary	B	AN	25	1
FL58	Insured's Name - Tertiary	C	AN	25	FL58	Insured's Name - Tertiary	C	AN	25	1
FL59	Patient’s Relationship - Primary	A	AN	2	FL59	Patient’s Relationship - Primary	A	AN	2	1
FL59	Patient's Relationship - Secondary	B	AN	2	FL59	Patient's Relationship - Secondary	B	AN	2	1

UB-92

FL Description Line Type Size

FL59 Patient's Relationship -Tertiary C AN 2

FL60 CERT./ SSN/ HIC/ ID NO. - Primary A AN 19 FL60 CERT./ SSN/ HIC/ ID NO.- Secondary B AN 19 FL60 CERT./ SSN/ HIC/ ID NO. - Tertiary C AN 19

FL61 Insurance Group Name - Primary A AN 14 FL61 Insurance Group Name -Secondary B AN 14 FL61 Insurance Group Name - Tertiary C AN 14

FL62 Insurance Group Number - Primary A AN 17 FL62 Insurance Group Number - Secondary B AN 17 FL62 Insurance Group Number - Tertiary C AN 17

FL63 Treatment Authorization Code - Primary A AN 18

Treatment Authorization Code -FL63 Secondary B AN 18 FL63 Treatment Authorization Code - Tertiary C AN 18

FL64 Employment Status Code - Primary A N 1 FL64 Employment Status Code - Secondary B N 1 FL64 Employment Status Code - Tertiary C N 1

FL65 Employer Name - Primary A N 24 FL65 Employer Name - Secondary B N 24 FL65 Employer Name - Tertiary C N 24

FL66 Employer Location - Primary A AN 35 FL66 Employer Location - Secondary B AN 35 FL66 Employer Locations -Tertiary C AN 35

FL67 Principal Diagnosis Code 1 AN 6

FL68 Other Diagnoses 1 AN 6 FL69 Other Diagnoses 1 AN 6 FL70 Other Diagnoses 1 AN 6 FL71 Other Diagnoses 1 AN 6 FL72 Other Diagnoses 1 AN 6 FL73 Other Diagnoses 1 AN 6 FL74 Other Diagnoses 1 AN 6 FL75 Other Diagnoses 1 AN 6

Admitting Diagnosis/Patient’s Reason for FL76 Visit 1 AN 6

* FL68,75,80 Size Updated 6/21/05UB-04 ** FL07, 30 Size Updated 12/15/05

Buffer
FL	Description		Line	Type	Size	Space Notes
FL59		Patient's Relationship - Tertiary	C	AN	2	1
FL60		Insured's Unique ID - Primary	A	AN	20
FL60		Insured's Unique ID - Secondary	B	AN	20
FL60		Insured's Unique ID - Tertiary	C	AN	20
FL61		Insurance Group Name - Primary	A	AN	14	1
FL61		Insurance Group Name -Secondary	B	AN	14	1
FL61		Insurance Group Name - Tertiary	C	AN	14	1
FL62		Insurance Group Number - Primary	A	AN	17	1
FL62		Insurance Group Number - Secondary	B	AN	17	1
FL62		Insurance Group Number - Tertiary	C	AN	17	1
FL63		Treatment Authorization Code - Primary	A	AN	30	1
Treatment Authorization Code -
FL63		Secondary	B	AN	30	1
FL63		Treatment Authorization Code - Tertiary	C	AN	30	1
FL64		Document Control Number	A	AN	26
FL64		Document Control Number	B	AN	26
FL64		Document Control Number	C	AN	26
Deleted from UB-04
Deleted from UB-04
Deleted from UB-04
FL65		Employer Name - Primary	A	AN	25
FL65		Employer Name - Secondary	B	AN	25
FL65		Employer Name - Tertiary	C	AN	25
Deleted from UB-04
Deleted from UB-04
Deleted from UB-04
FL66		DX Version Qualifier		AN	1		New
							Denotes ICD v.
FL67		Principal Diagnosis Code		AN	8		Expanded field
FL67A Other Diagnosis				AN	8		Expanded field
FL67B Other Diagnosis				AN	8		Expanded field
FL67C Other Diagnosis				AN	8		Expanded field
FL67D Other Diagnosis				AN	8		Expanded field
FL67E Other Diagnosis				AN	8		Expanded field
FL67F Other Diagnosis				AN	8		Expanded field
FL67G Other Diagnosis				AN	8		Expanded field
FL67H Other Diagnosis				AN	8		Expanded field
FL67I Other Diagnosis				AN	8		New
FL67J Other Diagnosis				AN	8		New
FL67K Other Diagnosis				AN	8		New
FL67L Other Diagnosis				AN	8		New
FL67M Other Diagnosis				AN	8		New
FL67N Other Diagnosis				AN	8		New
FL67O Other Diagnosis				AN	8		New
FL67P Other Diagnosis				AN	8		New
FL67Q Other Diagnosis				AN	8		New
FL68		Unlabeled	1a	AN	8*
FL68		Unlabeled	1b	AN	9*
FL69		Admitting Diagnosis Code	1	AN	7		Expanded by 1
FL70		Patient's Reason for Visit Code	A	AN	7		Distinct FL
FL70		Patient's Reason for Visit Code	B	AN	7		Distinct FL
FL70		Patient's Reason for Visit Code	C	AN	7		Distinct FL

							* FL68,75,80 Size Updated 6/21/05
	UB-92				UB-04		** FL07, 30 Size Updated 12/15/05
								Buffer
FL	Description	Line	Type	Size	FL Description	Line Type Size		Space Notes
					FL71 PPS Code	1	AN 3	2 New
FL77	External Cause of Injury Code	1	AN	6	FL72 External Cause of Injury Code	1a	AN 8
					FL72 External Cause of Injury Code	1b	AN 8	New
					FL72 External Cause of Injury Code	1c	AN 8	New
FL78	Unlabeled				FL73 Unlabeled	1	AN 9
FL79	Procedure Coding Method Used	1	N	1	Deleted from UB-04			Deleted
FL80	Principal Procedure Code/Date	1	N/N	6/6	FL74 Principal Procedure Code/Date		N/N 7/6	1/1 Expanded by 1
FL81	Other Procedure Code/Date	A	N/N	6/6	FL74a Other Procedure Code/Date		N/N 7/6	1/1 Expanded by 1
FL81	Other Procedure Code/Date	B	N/N	6/6	FL74b Other Procedure Code/Date		N/N 7/6	1/1 Expanded by 1
FL81	Other Procedure Code/Date	C	N/N	6/6	FL74c Other Procedure Code/Date		N/N 7/6	1/1 Expanded by 1
FL81	Other Procedure Code/Date	D	N/N	6/6	FL74d Other Procedure Code/Date		N/N 7/6	1/1 Expanded by 1
FL81	Other Procedure Code/Date	E	N/N	6/6	FL74e Other Procedure Code/Date		N/N 7/6	1/1 Expanded by 1
					FL75 Unlabeled	1	AN 4*	0*
					FL75 Unlabeled	2	AN 4	1
					FL75 Unlabeled	3	AN 4	1
					FL75 Unlabeled	4	AN 4	1
FL82	Attending Physician ID	a	AN	23	FL76 Attending - NPI/QUAL/ID	1	AN/AN/AN 11/2/9	New Layout
FL82	Attending Physician ID	b	AN	32	FL76 Attending - Last/First	2	AN/AN 16/12	New Layout
FL83A	Other Physician ID	a	AN	25	FL77 Operating - NPI/QUAL/ID	1	AN/AN/AN 11/2/9	New Layout
FL83A	Other Physician ID	b	AN	32	FL77 Operating - Last/First	2	AN/AN 16/12	New Layout
							AN/AN/
FL83B	Other Physician ID	a	AN	25	FL78 Other ID - QUAL/NPI/QUAL/ID	1	AN/AN 2/11/2/9	New Layout
FL83B	Other Physician ID	b	AN	32	FL78 Other ID - Last/First	2	AN/AN 16/12	New Layout
							AN/AN/
					FL79 Other ID - QUAL/NPI/QUAL/ID	1	AN/AN 2/11/2/9	New
					FL79 Other ID - Last/First	2	AN/AN 16/12	New
FL84	Remarks	1	AN	43	FL80 Remarks	1	AN 19*	Reduced Field Size
FL84	Remarks	2	AN	48	FL80 Remarks	2	AN 24*	Reduced Field Size
FL84	Remarks	3	AN	48	FL80 Remarks	3	AN 24*	Reduced Field Size
FL84	Remarks	4	AN	48	FL80 Remarks	4	AN 24*	Reduced Field Size
					FL81 Code-Code - QUAL/CODE/VALUE	a	AN/AN/AN 2/10/12	New
					FL81 Code-Code - QUAL/CODE/VALUE	b	AN/AN/AN 2/10/12	New
					FL81 Code-Code - QUAL/CODE/VALUE	c	AN/AN/AN 2/10/12	New
					FL81 Code-Code - QUAL/CODE/VALUE	d	AN/AN/AN 2/10/12	New
FL85	Provider Rep. Signature	1	AN	22	Deleted from UB-04
FL86	Date Bill Submitted	1	Date	6	Deleted from UB-04; See FL45, line 23

3. Improved Information Technology

CMS has simplified the claims submission process, effective July 1996, by accepting only national standard electronic claim formats. This means that CMS only accepts electronic claims in the American National Standards Institute (ANSI) 837 4010A1 format for institutional providers.

Through the use of the uniform bill, we have been able to achieve a more uniform and a more automated bill processing system for fiscal intermediaries and providers. This form is consistent with the CMS electronic billing specifications, i.e., all coding data element specifications are identical. This has promoted and eased the conversion to electronic billing. Provider billing costs have decreased as a result of standardization of bill preparation, related training and other activities. The average cost to process a line 1 Part A claim in FY 2004 was $.92 per claim.

In the electronic media claims process, the Medicare intermediary adjudicates the bill using its computer system after obtaining approval from CMS's Common Working File (CWF) system.

4. Duplication of Efforts

Most hospitals participate in both Medicare and many other insurance programs and, without use of the CMS-1450, would have to maintain distinct and duplicate billing systems to handle the billing form, the tape formats, and the diagnostic coding systems for the many programs. The purpose of the requirements in this package is to eliminate this duplication. There is no one form that can accommodate as much information as the CMS-1450 does; nor is there another that can handle a variety of services the way the uniform bill does.

The CMS-1450 is managed by the National Uniform Billing Committee, a standard’s body sponsored by the American Hospital Association. Most major payers, such as the Blues network, the members of the Health Insurance Association of America, as well as the state hospital associations, are represented on this body.

5. Small Businesses

Burden can be minimized by providing training materials and by obtaining assistance from the uniform bill coordinator designated by each CMS regional office.

6. Less Frequent Collection

The use of the UB-04 will not result in less frequent collection than obtained using the UB-92.

7. Special Circumstances

There are no special circumstances.

8. Federal Register Outside Consultation

We published a notice with a 60-day comment period proposing the information collection on February 24, 2006.

9. Payments/Gifts To Respondents

There are no payments and gifts to respondents.

10. Confidentiality

Privacy Act requirements have already been addressed under a Notice Systems of Record entitled "Intermediary Medicare Claims Record" system number 09-70-0503, DHHS/CMS/OIS.

11. Sensitive Questions

No questions of a sensitive nature are asked.

12. Burden Estimates (Hours & Wages)

Currently 98.8 percent of all Medicare intermediary bill receipts are EMC. Application of this percentage to our calendar year 2005 volume of 174,461,278 bills results in the following estimate of burden:

Hardcopy bills at 1.2% = 1.2% x 179,489,721 bills = 2,054,917 bills

Hardcopy burden = 9 minutes per hardcopy bill x 2,054,917 =

308,237 hours

EMC bills at 98.8% = 98.8% x 179,489,721 = 177,335,844 bills

EMC burden = 0.5 minutes per EMC bill x 177,335,844 bills = 1,477,799 hours

Total burden: 308,237 Hardcopy burden

1,477,799 EMC burden

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1,786,036 Total burden

Since the UB-04 will be completed by clerical staff or contractor billing staff, it is unclear of the total wages necessary to complete the form.

13. Capital Cost

There is no capital or operational costs associated with this collection.

14. Cost to the Federal Government

The annual costs to the Federal government for the information collection activity include all aspects of the data collection function from the initial data entry to receipt/processing operations. The costs to the Federal Government for data collection can best be described as the total costs of processing the required billing information. Calculation of the precise costs for the data collection is not feasible for the purposes of the Paperwork Reduction Act without conducting a costly study. Therefore, aggregate costs have been developed taking into consideration programming, software, training, tapes, overhead costs, etc.

15. Changes to Burden

The previous OMB approved burden submission was for the UB-92 renewal. This is a new burden for the UB-04.

16. Publication/Tabulation Dates

The purpose of this data collection is payment to providers for Medicare services rendered. We do not employ statistical methods to collect this information, but rather all Medicare institutional providers generate this billing information subsequent to the delivery of services.

17. Expiration Dates

Previous forms have been cleared without the expiration date present. Placing the expiration date of the form would require form changes. Since CMS is not responsible for the design and content of the UB-04 we would have to seek approval from the NUBC, which has responsibility for the UB-04, to make the change.

18. Certification Statement

There are no exceptions to the certification statement.

3. Collection of Information Employing Statistical Methods

This information collection does not employ statistical methods.

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