The Uses of Claim Form UB 04

There are various claim reimbursement forms; however, each claim form can be used for some specific purpose only including claim form UB 04. The UB04 claim form is used by facilities rather than physicians for their health insurance billing.  Hospitals, rehabilitation centers, ambulatory surgery centers, clinics, etc need to bill their services on the UB04 form in order to get paid.  There are certain exceptions as for example a person might have to admit their family member into a drug and alcohol rehab facility and then find that the facility doesn't participate with their insurance plan.  These facilities often don't file UB04 forms and can not help the family get reimbursed by the insurance company.

Many times the family might have paid upfront for the services of the facility and are may be trying to get the insurance company to reimburse them.  The insurance policy may pay out of network but the claim must be filed correctly on a UB04 form.  The UBO4 requires a few fields which are totally different than fields required on the CMS form. Some of these fields include Rev Codes, type of bill, condition codes, and value codes which can make it terribly confusing to the biller only familiar with CMS forms. In order to get UB04 claims paid, the biller must learn what these fields are and how to complete them correctly for their situation. Many of the other fields on the UBO4 form are similar to the CMS form but these few different ones must be completed correctly.

It is not unusual for many of the clinics and facilities to be out of network with most insurance carriers and therefore not billing on the UB04 forms as they are not billing the insurance carriers, they are collecting the payment from the patients. But some of these patients are finding out that they have out of network benefits which mean the insurance carrier would reimburse them for all or part of the expenses. The patients are then responsible for billing the insurance carriers. The insurance carriers may then demand that the claims be submitted on UB04 forms.

No matter who is submitting the facility claims, the claim form UB 04 must be completed correctly for the insurance carriers to reimburse the payment.