UB-04 Guide

UB-04 Guide

I.  Settings & Directories:
 
A.  Group Level Settings

1. Sites/Letterheads

  1. Create New Facility if needed.
  2. Make sure to use 9-digit zip code.
  3. Push information to Letterhead tab.
  4. Push information to Electronic Billing tab.
  5. NOTE: Service Facility Address displays in Box 1 and 2 of UB04.
  6. No Save button is necessary for this section.


2. Service/Mod Codes

  1. Select CPT/HCPCS code for appropriate setting.
  2. Enter in Revenue codes and appropriate daily rates.
  3. Link the Revenue codes to the corresponding CPT/HCPCS code.
  4. Enter the modifiers your facility uses in Modifier Code Short List, if applicable.

 
3. Insurance Payers 

  1. Click  to add a new insurance.
  2. Enter in at least the details highlighted in yellow.
  3. Make sure you have the Institutional Payer IDs for UB04, not the Professional Payer IDs for CMS 1500/HCFA forms.
  4. Click .
  5. If you need edit any existing insurance, click on the payer name in the left column, edit it and then click on .
  6. Changes will update for all patients who have previously been assigned to that payer via the Short List of Insurance Payers.

 
B. Specific to Individual Level Settings

1. Personal Info

  1. To be completed for each individual provider.
  2. Fill in at least the yellow required fields.
  3. To go to next provider, click on their name in the left column. If you do not see a list of names, then you do not have access and need to refer to your Administrator.
  4. No Save button is necessary for this section.

 
2. Billing Rates & Payer Rules

  1. To be completed for each individual provider.
  2. Click on the Short List option and use drop-down arrows to select codes from the previously created Short List in the Service Codes/Mod tab.
  3. If applicable, select modifiers next to codes.
  4. Enter in the corresponding billing rates, i.e. 100 for $100.00.

 
  1. Enter Provider Payer Rules if applicable, i.e. Billing under Supervisor or taxonomy code for specific insurance payers.
  2. No Save button is necessary for this section.

 
II.  Patient Demographics
 
A. Patient Info

 
Ensure the required billing fields are entered in addition to the following:

  1. Date of Current Admission: From XXXXX



  1. Date of Discharge (if applicable): To XXXXX
  2. Release of Information: Y or N


 
B. Insurance Info
 
Ensure the required billing fields are entered in addition to the following with the UB04 Payer ID:
 
 
Assignment of Benefits:  Yes or No

 
III.  Patient Accounts

  1. Access the UB-04 tab for the patient.
  2. Click  button to create new UB04 form.
  3. Select the stay you want to bill and click , or simply click  to skip this step.  (These dates are pulled from the Demographics.)


4. To edit current UB04, click the Edit pencil next to the one you want to edit.


 
IV.  UB04 Form in ICANotes
 
A. Organizational Details (Box 1-6)

  1. Provider Name: Settings & Directories, Group Level, Sites/Letterheads
  2. Beneficiary Name: Settings & Directories, Group Level, Sites/Letterheads
  3. Patient Control # and Medical Record #: Demographics, Patient Info
  4. Type of Bill, i.e. 131 for IOP
  5. FED Tax #: Settings & Directories, Specific to Individual, Personal Info
  6. Statement Covers Period From XX/XX/XXXX To XX/XX/XXXX.

 
B. Patient (Box 8-41)

    8. Patient Name and Patient ID
    9. Patient Address, City, State and Zip
    10. DOB = Date of Birth
    11. Sex = M, F, U
    12. Date = Admission Date
    13. Hour = Admission Hour, two digits
    14. Type = Admission Type
    15. SRC = Admission Service
    16. DHR = Discharge Hour, two digits
    17. STAT = Discharge Status, i.e. 30 still a patient, 01 discharge to home.
    18 - 30 = Condition Codes and Accident State – Not usually applicable to IOP
    31 - 36 = Occurrence Codes, Dates and Span – Not usually applicable to IOP
    38. = Responsible Part Name: Demographics, Insurance Info
    39 - 41 = Value Codes and Amounts – Not usually applicable to IOP

 
C.  Services (Box 42-48)

    42. = Revenue Code: Settings & Directories, Group Level, Service/Mod Codes
    43. = Description and Clinician
    44. = HCPCS Code: Can be linked to Revenue Code so it populates when Revenue Code is selected.
    45. = Date of Service – With IOP, each date will need to be entered individually.
    46. = Service Units
    47. = Total Charges
    48. = Non-Covered Charges


 
Completed for Statement Period:
 
 
 
D. Coverage (Box 50-62)
 
    50. = Payer Name: Demographics, Insurance Info
    51. = Health Plan ID: Demographics, Insurance Info
    52. = RFL: Y or N - Is there a release of information on file?
    53. = Ass. Ben = Y or N - Is there an Assignment of Benefits?
    54. = Prior Payment
    55. = Estimated Amount Due
    56. = NPI
    57. = Other Provider ID
    58. = Insured’s Name
    59. = P. REL: Patient Relationship to the Insured, i.e. 18 is Self and 02 is Spouse
    60. = Insured’s Unique ID: SSN – Demographics, Patient or Insurance Info
    61. = Group Name: Secondary Insurance, if applicable.
    62. = Insurance Group Name, if applicable.



E. Other Codes (Box 63-81)
 
    63. = Treatment Authorization Codes: Pre-authorizations from Chart Face
    64. = Document Control Number
    65. = Employer Name
    66. = DX Qualifier: 9 for ICD-9 and 10 for ICD-10
    67. = PPDX (Principal Diagnoses on Admission) and Additional Dx upon Admission
    68 - 69 = AdmitDX: Admitting Diagnosis
    70. = Patient Reason Dx: Patient’s Reason for Admission
    71. = PPS Code
    72. = ECl: External Cause of Injury Code
    74. = Procedure Codes and Dates
    76. = Attending: Provider Name & Identifiers: NPI, Last Name, First Name.
    77. = Operating: Provider Name & Identifiers: NPI, Last Name, First Name.
    78 - 79. = Other: Operating: Provider Name & Identifiers: NPI, Last Name, First Name.
    81. = Code-Code: Enter B3 in the qualifier if locations 76-79 contain an NPI. Enter the corresponding provider taxonomy of provider NPI’s entered in locations:
  1. 76a – 81CCa
  2. 77b – 81CCb
  3. 78c – 81CCc
  4. 79d – 81CCd


 
 V.  Where to Go from Here
 
A.  Print the UB04 onto a blank official UB-04 Form.

 

B.  Create a Print Image of the form.
1. Click 

2. Log into the Upload Site: upload.icanotes.com

3. Search for “Electronic” and click on the file.     
                             
  

4. Click on  folder.

5. The file will be labeled in this format:
                eBillingClaimsYYYYMMDDHHMMSSAM.txt
                31/10/2023 at 2:16:18 PM = eBillingClaims20231031021618PM.txt
 
6. Click on the paper icon to download the file.

7. Log into your clearinghouse and upload the file from your Downloads folder on your local computer.

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