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A Complete Guide to UB-04 Forms for Mental and Behavioral Health Providers

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Currently, 98% of hospital claims for healthcare are submitted electronically using UB-04 forms – but the process of filling them out is still manual for a majority of providers. As with any medical form, there are plenty of nuances, caveats, and complexities involved in UB-04 forms. So, let’s look at what role UB-04 forms play in behavioral health agencies, how to best utilize a UB-04 form, and how TenEleven’s EHR software can help.   

What Are UB-04 Forms? 

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 ushered in a new wave of administrative simplicity for healthcare coding and billing. Answering the call for standardization, The National Uniform Billing Committee (NUBC) — a governing body of billing code standards — swiftly created a uniform billing standard: UB-04.  

The Importance Of UB-04 Forms to Mental and Behavioral Healthcare Providers 

Can the UB-04 form be complicated? Yes. Is it better than converging a plethora of different forms to process patient medical claims? Absolutely. The UB-04 form cuts down the administrative workload for you and billing staff. Not only is the UB-04 maintained by a joint collaboration between the American Hospital Association (AHA) and the NUBC, but it’s a universal, regularly updated, and clearly organized form that can help you reduce administrative headaches, alleviate claim frictions, and expedite patient claims. The biggest reason that UB-04 forms are important is simple: most insurance providers require them. Maximizing patient claims is a surefire way to maintain a steady revenue stream to help you combat other healthcare frictions (e.g., payer mix changes, regulatory oversight, etc.) 

5 Tips for Filling Out UB-04 Forms 

Here are some tips to help you fill out the form accurately and timely. 

  1. Always consult with the NUBC manual for accurate codes.
  2. Check with insurance companies to ensure that your data is accurate.
  3. Use the appropriate ICD-10 codes when required.
  4. Always enter patient information exactly how it appears on their insurance card.
  5. Double-check date and time formats to ensure accuracy.  

UB-04 Vs. CMS-1500 

The National Uniform Billing Committee (NUBC) is responsible for the creation of both the UB-04 and CMS-1500 forms. These are sister forms created for the same purpose — uniform billing and administrative simplicity. There are some obvious differences in coding structure and form layout, but that’s due to one overarching difference between the forms: UB-04 is for healthcare systems, and CMS-1500 is for individual providers. In other words, if you work in a behavioral healthcare practice or clinic setting, you will use the UB-04. If you are a doctor or physician, you will use the CMS-1500. 

TenEleven’s UB-04 Form Capabilities  

TenEleven offers a custom eCR™ for a number of service types and levels of care, including behavioral health, mental health, addiction treatment, and family services. Whether you provide inpatient services, outpatient services, our Trauma Informed Care, eCR™ is built to fit you and your agency.  

TenEleven is one of only a few systems with the exclusive ability to process UB-04 forms electronically and automatically within our software.  

Our form library includes thousands of forms that are categorized and easy to find – or create your own forms in collaboration with our team utilizing FormLab™.   

Breaking Down the Fields of the UB-04 Form 

Every field of the UB-04 has a specific purpose and requires unique information. NUBC considers these fields “form locators” (FL). 

Form Locator 1 

  • Line 1: Provider Name
  • Line 2: Street Address
  • Line 3: City, State, and Zip
  • Line 4: Telephone Number, Fax Code, and Country Code 

Form Locator 2:
You only need to fill out this form if the pay-to name is different from field 1. 

  • Line 1: Pay-to Name 
  • Line 2: Street Address 
  • Line 3: City, State, and Zip 
  • Line 4: NOT USED 

Form Locator 3 (a/b): Enter the patient number & medical record number 

Form Locator 4: This is where you enter the type-of-bill (TOB). This is a four-letter code that determines the specific type of bill (e.g., outpatient, inpatient, etc.) The first digit is a zero, the second two digits indicate the type of bill, and the fourth number indicates the frequency of the bill. 

Form Locator 5: This is for your federal tax number. 

Form Locator 6: Enter the “from” and “through” service data in this field in the MMDDYY format. If this is a single-day billing, enter the date in both the “from” and through “section.” 

Form Locator 7: NOT USED 

Form Locator 8: Enter the patient’s name (last, first, MI). 

Form Locator 9: Enter the patient’s mailing address (Street number/PO box, city, state, zip). 

Form Locator 10: Enter the patient’s date-of-birth. 

Form Locator 11: Enter the patient’s sex (M or F). 

Form Locator 12: Enter the date-of-admission or the date of care. 

Form Locator 13: Enter the time of admission in military time with 2 characters. 

Form Locator 14: Enter the 1-digit code indicating the priority of this visit. 

Form Locator 15: Enter the 1-digit code indicating the source of referral for this visit. 

Form Locator 16: Enter the time of discharge in military time with 2 characters. 

Form Locator 17: This is the discharge status line. Use the correct two-digit code from the NUBC manual. 

Form Locator 18 – 28: These are all condition codes. Again, use the NUBC manual to insert any applicable codes on these eleven lines. 

Form Locator 29: This is an accident code. You can use the NUBC to find the two-digit code relating to the accident. 

Form Locator 30: NOT USED 

Form Locator 31 – 34: These lines are for any occurrence codes and dates from the NUBC manual. 

Form Locator 35 – 36: These lines are for any occurrence span codes and dates (MMDDYY). 

Form Locator 37: NOT USED 

Form Locator 38: Enter the name and address of the individual or party responsible for the bill. 

Form Locator 39 – 41: These lines are for value codes and amounts for any special circumstances. Again, consult the NUBC manual. 

Form Locator 42: Enter the appropriate revenue code from the NUBC manual. 

Form Locator 43: Enter the revenue code description from the code above, Investigational Device Exemption (IDE) number, or Medicaid drug rebate NDC (National Drug Code). 

Form Locator 44: Enter the HCPCS (Healthcare Common Procedure Coding System), HIPPS (Health Insurance Prospective Payment System) rate codes, or any accommodation rates codes on this line. 

Form Locator 45: Enter the service dates (MM/DD/YY). 

Form Locator 46: Enter the number of service units (e.g., visits, days, etc.) 

Form Locator 47: Enter the total charges related to the NUBC manual code from field 42. 

Form Locator 48: Enter any non-covered charge related to the NUBC manual code from field 42. 

Form Locator 49: NOT USED 

Form Locator 50: Enter all payers names in order of their liability (e.g., primary, secondary, tertiary, etc.) 

Form Locator 51: Enter the Health Plan ID of any payers above. 

Form Locator 52: Enter the appropriate code to signify any release of information from the payer names on line 50. 

Form Locator 53: Enter the assignment of benefits from the payer names on line 50. 

Form Locator 54: Enter the amount of money (in dollars and cents) received toward the payment of this bill prior to submitting the form. 

Form Locator 55: Enter the estimated amount due. 

Form Locator 56: Enter the 10-digit National Provider ID. 

Form Locator 57: Enter the 7-digit number for other providers if required. 

Form Locator 58: Enter the insured’s name. 

Form Locator 59: Enter the patient’s relationship to the insured. 

Form Locator 60: Enter the insured’s unique identifier (16-digit ID) 

Form Locator 61: Enter the insured’s group name. 

Form Locator 62: Enter the insured’s group number. 

Form Locator 63: Enter the treatment authorization code. 

Form Locator 64: Enter the document control number (a.k.a the internal control number) 

Form Locator 65: Enter the employer’s name. 

Form Locator 66: Enter the Dx and Procedure Code Qualifier. 

Form Locator 67: Enter the  ICD-9-CM diagnosis code and POA indicators. 

Form Locator 68: NOT USED 

Form Locator 69: Enter the ICD-9-CM diagnosis or reason for the visit. 

Form Locator 70: Enter the patient’s reason for visit codes. 

Form Locator 71: NOT USED 

Form Locator 72: Enter the ICD-9-CM code for the external cause of injury. 

Form Locator 73: NOT USED 

Form Locator 74: Enter other procedure code and date in this line. 

Form Locator 75: NOT USED 

Form Locator 76: Enter the attending provider’s name and identifiers 

Form Locator 77: Enter the operating physician’s ID. 

Form Locator 78 – 79: Enter other provider’s names and identifiers. 

Form Locator 80: Enter any special remarks. 

Form Locator 81: Enter any additional codes relating to another Form Locator overflow. 

It takes a lot to run a behavioral healthcare clinic. Between patient demands, regulatory pressures, and payer mix changes, there is a lot to keep up with. Form errors can lead to lost revenue and denied insurance claims. At TenEleven, we help behavioral healthcare providers streamline and automate insurance billing and collections with industry-leading Revenue Cycle Management Solutions.  

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