This section was designed for the outdated ub92 form so you will notice some differences with the ub04 form.
Claim Question
The UB04 claim form (CMS 1450) has its set of claim questions. (See the samples for the exact questions asked.)
Insurance Forms
c. 511 - UB04 Form (CMS 1450)
This form is used to bill private insurance companies. The form prints out a full itemization of all charges entered.
d. 514 - UB04 Form (CMS 1450)
This form is used to bill Medicare. This form prints an accumulation of all charges with the same revenue code classification on one charge line. In the Pharmacy classification, Medicare requires a separate charge line for each different procedure code/HCPCS code.
e. 516 - UB04 Form (CMS 1450)
This form was created for the dialysis units in Tennessee and Alabama. It is very similar to the 514 with the following exceptions:
| • | no unit price is calculated or printed for dialysis treatments. |
| • | pharmacy charges (revenue code 250) do not have the corresponding procedure/HCPCS codes printed. |
| • | the description for each classification is gathered from the description for the research (revenue) codes. |
| • | data should be entered on a per day basis because one of the 514's function is to create a comment, for each classification, specifying the dates of service. |
Suppressing Boxes 80 & 81
Boxes 80 and 81 are filled in by SSI®. If you wish these boxes to be empty then you need to create a control file. To suppress the boxes on the 514 form, create a file named "M6R514.CTL" that contains the line "ub8081=no". This file must be located in each of your accounts, (e.g., \ssiwin\30xxxx, \ssiwin\30xxxx, etc.) or in \ssiwin\4.
This file can be created by typing at the prompt:
COPY CON M6R514.CTL [ENTER]
ub8081=no [ENTER]
Press the [F6] key [ENTER]
To create the M6R514.CTL you could duplicate the above directions or copy it from the M6R514.CTL by typing at the prompt:
COPY M6R514.CTL M6R514.CTL [ENTER]
Suppressing Box 6 on the 514
If you would like to leave box 6 blank then you need to create a control file. To suppress the box on the 514, create a file named "M6R514.CTL" that contains the line "ub6=no". This file will have to be located in each of your accounts, (e.g., \ssiwin\30xxxx, \ssiwin\30xxxx, etc.) or in \ssiwin\4.
This file can be created by typing at the prompt:
COPY CON M6R514.CTL [ENTER]
ub6=no [ENTER]
Press the [F6] key [ENTER]
It is possible that you will wish to suppress boxes 6, 80 & 81 on your 514's. In that case include both of these lines:
COPY CON M6R514.CTL [ENTER]
ub6=no [ENTER]
ub8081=no [ENTER]
Press the [F6] key [ENTER]
Suppressing Boxes 84, 85, 86
Boxes 84, 85 and 86 are filled in by SSI®. If you wish these boxes to be empty then you need to create a control file. To suppress the boxes on the 514 form, create a file named "M6R514.CTL" that contains the line "ub848586=no". This file will have to be located in each of your accounts, (e.g., \ssiwin\30xxxx, \ssiwin\30xxxx, etc.) or in \ssiwin\4.
This file can be created by typing at the prompt:
COPY CON M6R514.CTL [ENTER]
ub848586=no [ENTER]
Press the [F6] key [ENTER]
To create the M6R514.CTL you could duplicate the above directions or copy it from the M6R514.CTL by typing at the prompt:
COPY M6R514.CTL M6R514.CTL [ENTER]
Suppressing Box 22 on the 514
If you would like to leave box 22 blank then you need to create a control file. To suppress the box on the 514, create a file named "M6R514.CTL" that contains the line "ub22=no". This file will have to be located in each of your accounts, (e.g., \ssiwin\30xxxx, \ssiwin\30xxxx, etc.) or in \ssiwin\4.
This file can be created by typing at the prompt:
COPY CON M6R514.CTL [ENTER]
ub22=no [ENTER]
Press the [F6] key [ENTER]
It is possible that you will wish to suppress boxes 22, 84, 85 and 86 on your 514's. In that case when creating the file include both of these lines:
COPY CON M6R514.CTL [ENTER]
ub22=no [ENTER]
ub848586=no [ENTER]
Press the [F6] key. [ENTER]
Champus Special Consideration: MTF
This is for a special type of Champus billing related to "resource sharing". A civilian provider who renders patient care at a Military Treatment Facility (MTF) as part of a Resource Sharing Agreement is required to do the following.
In addition to identifying the place of service as '26', the provider is required to identify the services as being rendered pursuant to a Resource Sharing Agreement. This is done by adding a three-digit extension to the tax identification number in box 25 of the CMS 1500 form. The information for Box 25 is entered on the Provider Entry screen. See the 'Tax ID' text box below:
How do you get the number to appear only on the forms where you want it and not on others? The simplest way is to bill for patient care in a separate patient account for this purpose. Set up a patient account just for those charges. This will help you keep the charges, payments, and adjustments organized and separate from other billing for the patient, if any. Add a Champus insurance company record just for this type of billing. For example, the provider renders the care at Castle Air Force Base. The 3-digit number for this air base facility is 017. The bill must go to:
PALMETTO GBA-CHAMPUS CLAIMS
ATTN: RESOURCE SHARING
P.O. BOX 870010
SURFSIDE BEACH SC 29587-8701
After the name of the insurance company above you would add: (MTF:017). The insurance company name would look like the following:
PALMETTO GBA-CHAMPUS CLAIMS (MTF:017)
The insurance creating program will look for the character sequence: "(MTF:". If this is found, the program will take the next 3 characters and add them to the tax ID and print the entire number in box 25.
Medicaid Insurance Information
Medicare Insurance Information
CHDP Form PM -160