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
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* FL68,75,80 Size Updated 6/21/05 |
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UB-92 |
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UB-04 |
** FL07, 30 Size Updated 12/15/05 |
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Buffer |
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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 |
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FL01 |
Provider Street Address |
2 |
AN |
25 |
FL01 |
Provider Street Address |
2 |
AN |
25 |
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FL01 |
Provider City, State, Zip |
3 |
AN |
25 |
FL01 |
Provider City, State, Zip |
3 |
AN |
25 |
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FL01 |
Provider Telephone, Fax, Country Code |
4 |
AN |
25 |
FL01 |
Provider Telephone, Fax, Country Code |
4 |
AN |
25 |
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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 |
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FL02 |
Pay-to City, State |
3 |
AN |
25 |
New |
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FL02 |
Pay-to ID |
4 |
AN |
25 |
New |
FL03 |
Patient Control Number |
1 |
AN |
20 |
FL03a Patient Control Number |
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AN |
24 |
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FL03b Medical Record Number |
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AN |
24 |
Moved/New |
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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 |
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FL05 |
Federal Tax Number |
2 |
AN |
10 |
FL05 |
Federal Tax Number |
2 |
AN |
10 |
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FL06 |
Statement Covers Period - From/Through |
1 |
N/N |
6/6 |
FL06 |
Statement Covers Period - From/Through |
1 |
N/N |
6/6 |
1/1 |
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FL07 |
Unlabeled |
1 |
AN |
7** |
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2 |
AN |
8** |
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FL07 |
Covered Days |
1 |
N |
3 |
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Eliminated - Substitute new Value Code |
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FL08 |
Non-covered Days |
1 |
N |
4 |
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Eliminated - Substitute new Value Code |
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FL09 |
Coinsurance Days |
1 |
N |
3 |
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Eliminated - Substitute new Value Code |
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FL10 |
Lifetime Reserve Days |
1 |
N |
3 |
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Eliminated - Substitute new Value Code |
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FL11 |
Unlabeled |
1 |
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12 |
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Eliminated |
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FL11 |
Unlabeled |
2 |
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13 |
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Eliminated |
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FL12 |
Patient Name |
1 |
AN |
30 |
FL08 |
Patient Name - ID |
1a |
AN |
19 |
New |
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FL08 |
Patient Name |
2b |
AN |
29 |
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FL13 |
Patient Address |
1 |
AN |
50 |
FL09 |
Patient Address - Street |
1a |
AN |
40 |
1 Discrete |
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FL09 |
Patient Address - City |
2b |
AN |
30 |
2 Discrete |
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FL09 |
Patient Address - State |
2c |
AN |
2 |
1 Discrete |
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FL09 |
Patient Address - ZIP |
2d |
AN |
9 |
1 Discrete |
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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 |
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Eliminated |
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FL17 |
Admission Date |
1 |
N |
6 |
FL12 |
Admission Date |
1 |
N |
6 |
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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 |
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AN |
17 |
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Moved to FL3b |
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FL24 |
Condition Codes |
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AN |
2 |
FL18 |
Condition Codes |
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AN |
2 |
1 |
FL25 |
Condition Codes |
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AN |
2 |
FL19 |
Condition Codes |
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AN |
2 |
1 |
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FL20 |
Condition Codes |
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AN |
2 |
1 |
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* FL68,75,80 Size Updated 6/21/05 |
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UB-92 |
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UB-04 |
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** FL07, 30 Size Updated 12/15/05 |
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Buffer |
FL |
Description |
Line |
Type |
Size |
FL |
Description |
Line |
Type |
Size |
Space Notes |
FL26 |
Condition Codes |
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AN |
2 |
FL21 |
Condition Codes |
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AN |
2 |
1 |
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FL22 |
Condition Codes |
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AN |
2 |
1 |
FL27 |
Condition Codes |
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AN |
2 |
FL23 |
Condition Codes |
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AN |
2 |
1 |
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FL24 |
Condition Codes |
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AN |
2 |
1 |
FL28 |
Condition Codes |
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AN |
2 |
FL25 |
Condition Codes |
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AN |
2 |
1 |
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FL26 |
Condition Codes |
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AN |
2 |
1 New |
FL29 |
Condition Codes |
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AN |
2 |
FL27 |
Condition Codes |
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AN |
2 |
1 New |
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FL28 |
Condition Codes |
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AN |
2 |
1 New |
FL30 |
Condition Codes |
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AN |
2 |
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FL29 |
Accident State |
1 |
AN |
2 |
1 New |
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FL30 |
Unlabeled |
1 |
AN |
12 |
** No "Xs" on proof |
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FL30 |
Unlabeled |
2 |
AN |
13 |
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FL31 |
Unlabeled |
1 |
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5 |
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FL31 |
Unlabeled |
2 |
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6 |
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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 |
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FL36 |
Occurrence Span Code/From/Through |
a |
AN/N/N |
2/6/6 |
1/1/1 New |
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FL36 |
Occurrence Span Code/From/Through |
b |
AN/N/N |
2/6/6 |
1/1/1 New |
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FL37 |
Unlabeled |
a |
AN |
8 |
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FL37 |
Unlabeled |
b |
AN |
8 |
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FL37 |
ICN/DCN |
A |
AN |
23 |
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Moved to FL64 |
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Relocated |
FL37 |
ICN/DCN |
B |
AN |
23 |
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Moved to FL64 |
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FL37 |
ICN/DCN |
C |
AN |
23 |
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Moved to FL64 |
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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 |
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* FL68,75,80 Size Updated 6/21/05 |
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UB-92 |
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UB-04 |
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** FL07, 30 Size Updated 12/15/05 |
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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 |
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FL43 |
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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 |
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FL45 |
Service Date |
1-23 |
N |
6 |
FL45 |
Service Date |
1-22 |
N |
6 |
0.5 |
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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 |
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Removed |
FL47 |
Total Charges |
1-23 |
N |
10 |
FL47 |
Total Charges |
1-23 |
N |
9 |
0.5 sign field |
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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 |
|
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|
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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.
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
--------------------------
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.
Collection of Information Employing Statistical Methods
This information collection does not employ statistical methods.
File Type | application/msword |
File Title | Supporting Statement and Supporting Regulations Contained in 42 CFR 424 |
Author | HCFA Software Control |
Last Modified By | CMS |
File Modified | 2006-05-01 |
File Created | 2006-02-16 |