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UB-04, Inpatient / OutpatientHospital (inpatient and outpatient), hospice, home health, rural health clinic, federally qualifiedhealth center, and birthing center must bill on a UB-04.UB-04 InstructionsThe blocks divided into rows A, B, C reflect the following:ABCPrimary PayerSecondary PayerTertiary PayerAll information in field 50, 54, 60, and 63 should follow the instructions listed below:Line A applies to payer ALine B applies to payer BLine C applies to payer CField Requirements: (Blank Not Required)CRRIRORNHConditionally RequiredRequired Field including Nursing HomeRequired InpatientRequired OutpatientRequired Nursing Home**Note – All requirements will be enforced on January 1, 2015. Failure to comply could result inclaim rejections.FormLocatorRequiredField1Field NameCommentsRProvider Name, Address, PhonenumberEnter the name, address, and phonenumber of the billing provider.Address includes street address, city,state and 9-digit ZIP Code.2CService Facility Name, Address,and IDEnter the service facility location’sname and address. Enter the servicefacility ID as:Provider 10-digit NPI, dash, three-digitfacility code.3ARPatient Control NumberAlphanumeric characters may be used(Maximum of 20). The patient accountnumber is printed on the remittanceadvice.Medical Record NumberAlphanumeric characters may be used(Maximum of 20). The medical recordnumber is not printed on theremittance advice.3B

FormLocatorRequiredFieldField NameComments4RType of BillEnter 0 then the appropriate three-digitcode for type of bill.Valid values are:11x Hospital Inpatient (IncludingMedicare Part A)12x Hospital Inpatient (Medicare PartB Only)13x Hospital Outpatient14x Hospital Other18x Hospital Swing Beds21x SNF Inpatient (Including MedicarePart A)22x SNF Inpatient (Medicare Part B Only)23x SNF Outpatient28x SNF Swing Bed32x Home Health34x Home Health71x Rural Health Clinic72x Outpatient ESRD73x Federally Qualified Health Center(FQHC)74x Outpatient Rehab Clinic77x Federally Qualified Health Center(FQHC)81x Hospice82x Hospice/Hospital Center83x Ambulatory Surgery Center84x Birthing Center85x Critical Access89x Inpatient Residential TreatmentCenter“X” indicates frequency.Valid values are:0 Zero Claim1 Admit thru Discharge2 Interim Bill - First Claim3 Interim Bill - Cont Claim4 Interim Bill – Final Claim5 Late Charge Only Claim7 Prior claim/Replacement8 Cancel of Prior Claim9 Final Claim for a Home Health PPSepisodePlease note: Values 2, 3, & 4 cannot beused on acute care hospital claims.

FormLocatorRequiredFieldField NameCommentsIf the frequency code indicates anadjustment of a prior claim (7, 8), theoriginal claim ID (as assigned by THP),must be referenced in field 64.5RFederal Tax IDEnter numeric 9-digit Federal Tax ID.6RStatement Covers PeriodFrom - ThroughEnter the dates of service covered bythe claim. Enter each date asMMDDCCYY or MMDDYYNote: Inpatient dates of service mustreflect the date of admission thru dateof discharge.7No entry required.8ARPatient IDEnter patient 11-digit THP member IDnumber exactly as it appears on thepatient’s ID card8BRPatient NameEnter patient Last, First Name9ARPatient AddressEnter Address9BRCityEnter City9CRStateEnter State9DRZip CodeEnter 9-digit ZIP Code9ECCountry CodeNo entry required.10RBirth DateEnter the patient’s date of birth.Must be valid date and formatMMDDCCYY.11RSexEnter the patient’s gender code: M(male), F (female), or U (unknown).12RI, RNHAdmission DateEnter the date that the patient wasadmitted to the facility.Must be valid date and formatMMDDYY or MMDDCCYY.13RI, RNHAdmission HourEnter the 2-digit hour the patientwas admitted using the militaryhour. Valid values are 00 – 23.14RI, RNHType of AdmissionEnter 1-digit admission type code.Valid values are 1, 2, 3, 4, or 9.15RSource of AdmissionEnter 1-digit admission source. Validvalues are 1 – 9.**Required for all inpatient andoutpatient services.16RI, RNHDischarge HourEnter 2-digit hour the patient wasdischarged using the militaryhour. Valid values are 00 – 23.

FormLocatorRequiredFieldField NameComments17RPatient StatusEnter 2-digit patient status code. Validvalues are 00 – 99.**Note: 5010 does not allow a ‘blank’for patient status. We will default to ‘01’until 12/31/2014 and then all ‘blanks’will reject.‘01’ Discharged to home or selfcare(routine discharge)C29Condition CodesEnter if applicable.Accident StateNo entry required.3031-34No entry required.COccurrence codes and datesRNH35-36CFor Inpatient Hospital:See instructions for billing no PART A atthe end of the UB billing instructions.Occurrence Span37For Inpatient Only:Enter the appropriate occurrencespan (format MMDDCCYY) beginningwith 35a and entering horizontallythrough 36a. When needed, continueentering spans using 35b and 36blisting them horizontally.No entry required.3839-41Enter the appropriate occurrencecodes and valid dates (formatMMDDCCYY) beginning with 31a andentering horizontally through 34a.When needed, continue enteringcodes and dates using 31b-34b listingthem horizontally.CResponsible Party Name andAddressNo entry required.Value Codes and AmountsEnter the appropriate value code(s)with the corresponding amount(s). Thefirst value code and amount areentered in block 39a. The secondthrough twelfth value codes andamounts are entered in 40A, 41A, 39B,40B, etc.Valid values are:06 Blood DeductibleA1 Deductible Payer AB1 Deductible Payer BC1 Deductible Payer C

FormLocatorRequiredFieldField NameCommentsA2 Coinsurance Payer AB2 Coinsurance Payer BC2 Coinsurance Payer CD3 Partial patient resource forNursing home, ICF/MR and hospiceservices provided in a nursing home80 Covered Days81 Non-Covered Days82 Coinsurance Days83 Lifetime Reserve Days31 Nursing home, ICF/MR andhospice services provided in a nursing42RRevenue CodeEnter the 4-digit revenue code.CRITICAL ACCESS HOSPITALS:If there is an assigned CPT or HCPCScode for a drug billed with revenuecodes 025X and 0636, it must be billedalong with the NDC information listedin Block 43 so drug rebates can becollected from drug companies.43CDescriptionWhen billing a CPT or HCPCS code fora drug, enter the NDC qualifier of N4,followed by the 11-digit NDC number,(space), and the unit of measurementfollowed by the metric decimalquantity or unit. Do not enter a space betweenthe qualifier and NDC. Do notenter hyphens or spaces within theNDC number.The NDC number being submittedto THP must be the actual NDCnumber on the package orcontainer from which themedication was administered.Refer to the drug code list on theBMS website for a list of drugs thatrequire NDC codes.Enter the NDC unit of measurementcode and numeric quantityadministered to the patient. Enter theactual metric decimal quantity (units)administered to the patient. Ifreporting a fraction of a unit, use a

FormLocatorRequiredFieldField NameCommentsdecimal point. The unit ofmeasurement codes are as follows:F2 -International UnitGR-GramML-Milliliter43Line 23CPageofUN- UnitExample N499999999999 ML22.4Refer to dhhr.wv.gov/bms foradditional billing instructions/FAQs.Required if continuous bill;Page 1 of 3, page 2 of 3, etc.44C, RNHHCPCS/Rates/HPPS codeEnter the appropriate CPT or HCPCSprocedure code, followed by up tofour 2-digit modifiers.Rates must be between 0 and99999999 ( 999,999.99).340B providers are required to use UDmodifier to indicate drugs used from340B stock45RO, RNHService DateEnter the line item service date (formatMMDDCCYY). This field is used only foroutpatient claims and nursing facilities.DOS must be within the last year, andprior to the receipt date.46RService UnitsEnter the number of times theprocedure billed was performed. Enternumber of covered days for inpatientonly.Note: Outpatient surgery andrecovery are to be billed in 15-minutetime increments.Observation is to be billed in one-hourunits. See Attachment 1 of theChapter 510 of the Provider Manual,dhhr.wv.gov/bms47RTotal ChargesEnter Total Charges.48CNon-Covered ChargesEnter Non-Covered Charge.49No entry required.50 A-CCPayer (A, B, C)51 A-CCProvider Number (A, B, C)52Release of Info CertificationEnter the name identifying each payerorganization from which the providerreceived payment for the bill.No entry required.

FormLocatorRequiredFieldField NameCommentsIndicatorAssignment of Benefits (CertIndicator)No entry required.Prior Payments (A, B, C)Enter the amount(s) paid by eachprimary carrier listed in field 50.Correspond the payment with thepayers in field 50. Attach a copy ofthe EOB from the insurance orMedicare carrier. If claim or claimlines are denied, include theexplanation of denial codes, ifapplicable, for claim processing.Estimated Amount DueNo entry required.NPIEnter in the provider NPI58Insured’s NameEnter insured’s name if applicable. LastName, First Name and Middle Initial.59Patient’s Relation to InsuredNo entry required.5354 A-CC5556R60RInsured’s Unique ID NumberEnter all of the insured’s unique IDnumbers assigned by each payerorganization. The member’s 11-digitTHP ID number must be entered andcorrespond with the Medicaid entry infield 50 A, B, or C.If Medicaid is primary, enter themember’s THP ID in Field 60A. IfMedicaid is secondary, enter themember’s THP ID in Field 60B. IfMedicaid is tertiary, enter themember’s THP ID in Field 60C.61CGroup NameEnter if applicable.62CInsurance Group NumberEnter if applicable.63CTreatment Authorization CodesEnter the prior authorization number ifapplicable. Correspond each priorauthorization number with the payer(s)listed in field 50 A, B, or C.64CDocument Control NumberEnter the original claimnumber. This is the claim ID tobe adjusted.**Required if the last digit of the claimfrequency code is 7 or 8 in Block 4.Employer NameNo entry required.ICD Code IndicatorEnter 0 for ICD-10.6566R

FormLocatorRequiredField67RField NameCommentsPrincipal Diagnosis Code andPOA Indicator (Required if inpatient)Enter the ICD-10 code for the principaldiagnosis in the unshaded area.Enter present on admission (POA)indicator in the shaded area:Y YesN NoU Documentation insufficient todetermineW Clinically undetermined67 A-QCOther Diagnosis Code and POAIndicator (Required if in-patient)Enter the other ICD-10 diagnosis codesin the unshaded code if applicable.Enter POA indicator in the shadedarea. See 67 above.No entry required.6869RIAdmitting Diagnosis CodeEnter the appropriate ICD-10admitting diagnosis code, ifapplicable.70A-CCPatient Reason Code for VisitEnter the appropriate ICD-9 or ICD-10reason code, if applicable.Required for all unscheduledoutpatient visits with a type of bill013X or 085X with a type of admission1, 2, or 5 and revenue codes of045X, 0516, 0526 or 762.7172CPPS codeNo entry required.External Cause of Injury CodeEnter the ICD-10 external cause ofinjury code(s) if applicable.No entry required.7374RIPrinciple Procedure CodesEnter the ICD-10 code and date(format MMDDCCYY) identifying theprincipal procedure for inpatientclaims only.74 A-ECOther Procedure CodesEnter other procedure code(s) anddate(s) (format MMDDCCYY) ifapplicable.75This field identifies the name and NPI ofthe individual with the primaryresponsibility for performing surgicalprocedures.Enter the operating physician’s NPI,

FormLocatorRequiredFieldField NameCommentsLast Name and First Name.76RAttending NPIQualLast Name First NameEnter in the attending physicians NPILast Name and First Name.77COperatingRequired when surgical procedure ison the claim.78/79COther ProvidersUse this field to report other providersinvolved with the patient’s care.Enter the provider’s NPI, Last Name andFirst Name. A qualifier must be used toindicate the type of provider.Qualifiers are:ZZ Other operating physicianDN Referring provider82 Rendering provider80RemarksNo entry required.81Code/CodeNo entry required.UB-04 Billing InstructionsRev. 7/21/2020

72x Outpatient ESRD 73x Federally Qualified Health Center (FQHC) 74x Outpatient Rehab Clinic 77x Federally Qualified Health Center (FQHC) 81x Hospice 82x Hospice/Hospital Center 83x Ambulatory Surgery Center 84x Birthing Center 85x Critical Access 89x Inpatient Residential Treatment Center "X" indicates frequency.