If you have ever wondered “in what format are healthcare claims sent?” this guide answers that question and shows how the right claim submission format keeps healthcare reimbursements moving.

A clean claim starts the payment clock. Use the wrong healthcare claims format or leave out key data, and the clock stops. Insurers then delay, reduce, or even refuse payment. Knowing what format healthcare claims are submitted in—and using it every time—guards your cash flow.

You will hear two close‑sounding terms: ‘form’ and ‘format’. They sound alike, but here’s an easy way to keep them straight:

• Form = paper. Think CMS‑1500 or UB‑04.
• Format = electronic. Think files that zip through secure networks.

That shift from form to format changes the game. Paper forms still work for a few small offices, yet they move at postal speed and add data‑entry risk. In contrast, an electronic medical claim form format reaches the payer in minutes and meets every HIPAA‑compliant medical claim format rule.

Most healthcare providers now rely on the HIPAA‑compliant 837 electronic insurance claim format because it moves fast and cuts errors. The 837 family has three files:

• 837P (Professional): office visits, lab work, therapy, and other outpatient care
• 837I (Institutional): hospital stays, skilled‑nursing days, and other facility fees
• 837D (Dental): cleanings, fillings, crowns, and all oral services

Additionally, pharmacies follow a different (but equally strict) insurance claim format called NCPDP for every prescription they fill.

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In the United States, healthcare claims move in matched pairs of paper and electronic files. When paper is still required, providers mail the CMS-1500 for office services, the UB-04 (CMS-1450) for hospital or facility charges, and the ADA Dental Claim for tooth work.

Day-to-day, those same claims travel faster as their electronic twins—the CMS-1500 turns into the 837P, the UB-04 turns into the 837I, the ADA form turns into the 837D, and every paper pharmacy slip converts to the NCPDP telecom file. All four digital files ride on secure EDI, making them the standard format for submitting medical claims today.

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What is meant by the ‘format’ of a Healthcare Claim?

When people ask “in what format are healthcare claims sent?” they are talking about the exact layout—paper or electronic—that tells an insurer who was treated, what was done, when it happened, and how much it cost. In the United States, providers must send this information in a HIPAA‑compliant medical claim format so the payer can read it, check it, and pay it without delay.

Every claim line follows a standard format for submitting medical claims and carries well‑known code sets:

• ICD‑10‑CM — pinpoints the diagnosis
• CPT® or HCPCS — shows the procedure or service
• NDC, HCPCS Level II, or revenue codes — identify supplies, drugs, devices, or medical transport

Using the right healthcare claims format reduces back‑and‑forth, slashes errors, and speeds up cash flow. Put simply, the format is the blueprint that turns clinical work into dollars received.

Who decides the healthcare claim submission format?

Before you hit “send,” you need to know who writes the rules. In U.S. healthcare, four main bodies define what format healthcare claims are sent in and how those files must look. Master their playbook, embed them in your practice management software, and your claims move from “pending” to “paid” much faster.

1). Centers for Medicare & Medicaid Services (CMS)

CMS issues the familiar paper layouts, called the CMS‑1500 for professional services and the UB‑04 for hospital billing and facilities. Even in an e‑first world, many healthcare payers still scan these forms, so clean, crisp fields matter. As a healthcare provider, you need to follow every box, line, and font cue so that your paper claim sails through optical‑character recognition with fewer manual touch‑ups.

2). Accredited Standards Committee X12 (often called ANSI X12)

When you switch to electronic, X12 owns the road. Its 837P, 837I, and 837D EDI loops translate your service lines into machine‑readable data. The latest release—HIPAA version 5010—locks down field length, segment order, and code sets. Submit an 837 file that matches X12 specs and most clearinghouses will approve it in minutes.

3). National Council for Prescription Drug Programs (NCPDP)

Need to bill a pharmacy claim? NCPDP frames the real‑time electronic medical claim format for retail, mail‑order, and specialty drugs. It syncs each NDC code, quantity, and day‑supply field so the payer’s drug‑utilization engine can check safety and price in a single ping.

4). Health Insurance Portability and Accountability Act (HIPAA)

HIPAA is the federal backbone. It mandates that every covered entity—clinic, dentist, hospital, or health plan—uses a HIPAA‑compliant medical claim format and safeguards patient data at rest and in flight. Fail to follow these guardrails and you risk fines, data breaches, and slow payment.

Types of Healthcare Claim Form formats

1). the CMS‑1500 Paper Claim Format

Even in the EDI era, some payers still need a paper file. That file is the CMS‑1500 form. It is the standard insurance claim format for solo doctors, therapists, labs, and other non‑facility providers. Think of it as the paper twin of an 837P file. If you mail or fax a claim, this is the one that lands on the payer’s scanner.

Why CMS‑1500 is a standard claim format?

The CMS‑1500 is more than a sheet of paper. It follows firm layout rules that turn your data into a machine‑ready healthcare claims format:

• Fixed field map. Each red box lines up with a matching data field in HIPAA’s 837P file. That one‑to‑one link keeps your claim submission format in sync whether you print or send EDI.
• Code sets locked in. The form forces you to use ICD‑10‑CM for diagnoses, CPT®/HCPCS for services, and your ten‑digit NPI for provider ID. Those sets make the file a HIPAA‑compliant medical claim format by design.
• Scanner‑friendly ink. The “drop‑out” red ink lets optical readers lift each character cleanly. A clear scan speeds the payer’s first‑pass edit and cuts denials.

Because its layout never changes, the CMS‑1500 acts as a standard format for submitting medical claims (even when you submit on paper).

Why polish your CMS‑1500 workflow?

• Fewer re‑works. A tight, HIPAA‑compliant medical claim format gets past OCR edits on the first scan.
• Quicker cash flow. Clean paper claims can still clear in ten business days. This is vital when clearinghouses are down.
• Easy pivot to EDI. Every well‑filled CMS‑1500 mirrors the field order of an 837P. When you upgrade, the map is ready.

2). the UB‑04 (CMS‑1450) Facility Claim Format

Hospitals, rehab centers, and skilled-nursing homes do not bill on the CMS‑1500 claim format. Instead, they use the UB‑04 form, also called CMS‑1450. This single page carries every charge for a full stay—room, board, drugs, supplies, lab work, even the swing‑bed fee. So if you ask in what format are healthcare claims sent for facilities?, the answer is almost always UB‑04 in paper or 837I in EDI.

What makes the UB‑04 a standard format?

• Fixed line map. Every line has a locator number (FL 01–81). That grid links one‑for‑one with the 837I segments in a HIPAA 5010 file, keeping your healthcare claims format consistent across paper and electronic routes.
• Revenue codes first. Each charge line starts with a three‑digit revenue code, then the CPT®/HCPCS code when needed. This layout meets the healthcare claim submission format requirements that drive auto‑adjudication.
• Header holds payer data. The top blocks lock in Medicare, Medicaid, or private plan IDs. Drop the wrong payer code and the claim bounces before anyone checks medical need.

Sections you must get right:

• Patient and subscriber data (FL 12–17). Copy the name, date of birth, and member ID exactly from the card.
• Occurrence and value codes (FL 31–41). These tiny two‑digit flags mark why the stay started, when benefits kicked in, and how much the patient paid.
• Service lines (FL 42–47). List each daily room rate, therapy charge, or drug cost on its own line so the payer’s system can total them.

3). the ADA Dental Claim Format

Dentists do not bill on a CMS form. They use the ADA Dental Claim Form, built by the American Dental Association for easy review by dental payers. It runs on paper or as an electronic flat file that mirrors its boxes.

Key details the form captures:

• Patient facts. Full name, birth date, address, policy or group number.
• Provider identity. Dentist’s name, NPI, practice address, phone, and pay‑to number.
• Service codes. Each procedure uses a CDT code (e.g., D1110 for adult cleanings).
• Tooth data. The form shows tooth numbers, surfaces, and quadrants to prove need.
• Clinical notes. A short box lets you add a narrative. This is beneficial for crowns, implants, or ortho claims because payers need clear proof of medical need (cracks, bone loss, malocclusion) before they sign off on these higher‑cost services.

Why this dental format matters?

• Uniform language. CDT codes and tooth charts let payers price claims fast.
• HIPAA alignment. The form meets HIPAA‑compliant medical claim format rules and maps straight to the 837D EDI file.
• Low denial risk. *Clear tooth surfaces and dates stop “lack of info” rejections that delay checks.

4). the Workers’ Compensation Claims Format

When an injury happens on the job, the claim does not go through a regular health plan. Instead, you bill the employer’s workers’ comp carrier in a special healthcare claims format that mixes state rules with HIPAA data sets.

What format are workers’ comp claims submitted in?

• Paper route. Many carriers still ask for a CMS‑1500 marked “Workers’ Compensation” in Box 10 d. Attach state‑required injury reports and mail the bundle to the adjuster.
• Electronic route. Larger payers accept an ANSI X12 837P or 837I file plus the state’s claim number in Loop 2300. This meets HIPAA‑compliant medical claim format rules while flagging the file as work‑related.

Either way, use the standard format for submitting medical claims. But add the extra comp fields listed below so the adjuster can link services to the injury event.

Must‑have fields that keep the claim moving:

• Employer data. Full company name, address, and the workers’ comp policy number prove coverage.
• Employee facts. Name, home address, birth date, and Social Security number pin the claim to one worker.
• Injury snapshot. Date, time, and place of the accident, plus a short injury story (e.g., “strained lower back lifting boxes”).
• Service lines. List each CPT® or HCPCS code, tied to ICD‑10‑CM trauma codes (S‑ and T‑series) that match the injury note.
• Claim number. The state or carrier issues this after the first report of injury. Put it on every claim so payment flows to the right file.

5). the Coordination of Benefits Claim Format

Patients who have two or more health plans need a clear hand‑off. That hand‑off happens in the Coordination of Benefits (COB) claim format—the fields inside every paper and electronic claim that tell payers who pays first and who pays next.

“Who pays first” means the primary plan—the policy that has the legal duty to process the bill before any other insurer. It allows or denies each charge, applies its own deductible or copay rules, and sends an Explanation of Benefits (EOB) that shows what it paid and what is still owed.

“Who pays next” refers to the secondary (or tertiary) plan. This plan cannot act until it sees the primary EOB. Once it has that record, it:

• checks the remaining balance,
• pays up to its own benefit limits, and
• may wipe out the left‑over patient share.

Example: A patient has an employer health plan and is also covered under a spouse’s plan. The employer plan is primary, so it handles the claim first. After it posts payment, you transmit the same claim—with the primary paid amount filled in—to the spouse’s plan. That plan is secondary and can now cover some or all of the leftover cost.

Stating this order in the COB claim format keeps every payer in line with federal Coordination‑of‑Benefits rules, stops over‑payment, and ensures the patient never gets billed twice for the same care.

When someone asks “in what format are healthcare claims sent when the patient has double coverage?” the answer is: CMS‑1500 or UB‑04 on paper, and ANSI X12 837 with COB loops on EDI.

What the COB data must show?

➜ Each policy in plain view

• Insurance name, plan type, and policy number
• Start and end dates so the payer sees the coverage line‑up

➜ Benefit check

• Does the plan pay primary or secondary on this visit?
• Any carve‑outs or limits that change how much it will cover

➜ Payment order

• You mark the primary carrier first, the secondary carrier second, and so on
• In an 837 file, this sits in Loop 2320—HIPAA’s built‑in spot for COB rules

Why the COB format cuts claim ping‑pong?

• Stops over‑payment. Clear policy data keeps payers from paying more than the charge.
• Speeds split‑payment. When the primary plan’s paid amount drops into the secondary plan’s field, the second payer can finish the bill without calling you.
• Meets every rule. COB elements sit inside the same HIPAA‑compliant medical claim format you already use, so you stay within federal privacy guardrails.

6). the Medicare and Medicaid Claim Form Formats

Federal payers follow strict layout rules. When you bill Medicare or Medicaid, you choose the claim format first, then you fit every field to the CMS guide.

Pick the right form or its EDI twin:

• CMS‑1500 / 837P – Use this medical claim format for professional work: office visits, lab draws, therapy, ambulance runs.
• UB‑04 / 837I – Use this format for facility fees: hospital stays, rehab days, dialysis, outpatient surgery.

Think of the paper form as a picture of the electronic file. The boxes on the page map line-for-line to the segments in the ANSI X12 file. That link keeps each claim HIPAA-compliant and easy to read by Medicare’s edits.

Key Medicare-Medicaid format rules:

• Use the right code sets. Stick to ICD‑10‑CM for the “why,” CPT®/HCPCS for the “what,” and revenue codes for room and board.
• Show the NPI every time. Place your ten-digit NPI in the provider ID box and in Loop 2010AA of the 837 file.
• Add the payer ID. Medicare uses payer ID “CMS.” State Medicaid plans list their own four- or five-character IDs—check your remittance advice if you forget.
• Lock the date style. Medicare denies claims with slashes. Enter dates as MMDDYYYY on paper and as CCYYMMDD in EDI.
• Include signature on file. On the CMS‑1500, mark “Signature on File” in Box 12 and Box 13. In the 837P use the HI segment flag. This shows you hold the patient’s consent.

Electronic Claim Formats

Manual Claim Formats

FAQs

What is primary and secondary insurance?

Primary insurance is the first plan that reviews your claim and pays up to its own benefit limits. Secondary insurance steps in after the primary issues an Explanation of Benefits (EOB) and covers some or all of the leftover bill. Clear COB data on your claim tells payers in what order to pay.

What is the difference between a claim form and a claim format?

Form = a paper document (CMS-1500, UB-04, ADA) you print, sign, and mail or fax.
Format = an electronic data file (837P, 837I, 837D, NCPDP) you send through EDI. Each format mirrors its paper twin and meets all HIPAA-compliant medical claim format rules.

What is the CMS-1500 form used for?

Providers submit professional services—office visits, therapy, lab draws—on the CMS-1500 paper claim form when electronic filing is not an option.

What is the UB-04 form used for?

Hospitals, rehab centers, and skilled-nursing homes bill inpatient stays and other facility fees on the UB-04 (also called CMS-1450) when a payer still requires paper.

What does the 837P format represent?

The 837P is the electronic medical claim form format that replaces the CMS-1500. It travels by HIPAA-secure EDI and speeds professional claim processing.

How does the 837P differ from the 837I?

The 837P carries professional claims (outpatient visits, ambulance runs). The 837I carries institutional claims (inpatient room charges, outpatient surgery). Both follow the ANSI X12 healthcare claims format.

Why do most payers prefer electronic submission?

Electronic claims reach payers in seconds, cut keystroke errors, and meet every healthcare claim submission format requirement under HIPAA. Faster in, faster paid.

What is EDI in healthcare billing?

Electronic Data Interchange (EDI) is the secure network that moves 837 claim files, 835 remittances, and 270/271 eligibility checks between providers and payers.

Can I still use paper claim forms under HIPAA?

Yes. Smaller clinics and some state programs may mail claims. Yet most carriers now ask, “in what format are healthcare claims sent?”—and expect the electronic answer. Submitting the correct electronic claim format (837P, 837I, 837D, or NCPDP) speeds payment and keeps you compliant.

How can a medical billing service help with claim submission and denial management?

A medical billing services company knows every healthcare claims format inside out. It scrubs your data before you send a CMS-1500, UB-04, 837P, or 837I, catching code or NPI errors that cause denials. The team transmits each claim through its own high-speed clearinghouse link, tracks the payer’s edits in real time, and fixes any rejections the same day. When a denial does occur, the service applies denial management best practices and pulls the EOB, adds the missing detail, files an appeal, and resubmits in the proper claim submission format (often within 24 hours).

In simpler terms, a medical claim form is a formal written request that a healthcare provider submits to an insurance company, Medicare or Medicaid, or another affiliated entity seeking compensation for the healthcare services provided to a patient.

Healthcare providers firmly believe that their patients are entitled to specific rules or statutes of insurance companies, and the medical claim form serves as a legal document that justifies the request for compensation.

The Types of Medical Claim Forms Used in the US Healthcare System

The US healthcare system relies heavily on medical claim forms to process reimbursement requests for services rendered by healthcare providers. These forms capture essential information about the patient, service details, diagnosis, and charges.

Here’s an overview of some common types of medical claim forms used:

• Institutional Claim Form (includes 837I, UB-04 Form)
• Professional Claim Form (includes CMS-1500, 837P)
• Dental Claim Form (includes ADA Dental Claim Form J400, 837D)

1). Institutional Claim Form

Institutional claims are claims that are filed by hospitals, clinics, and other healthcare facilities—rather than individual healthcare providers such as physicians or nurses—to seek compensation from insurers and other payers for services provided to patients. This claim form provides a comprehensive snapshot of the patient’s medical history, the services they received, and the associated costs.

⇉ Types of Institutional Claim Forms

When it comes to institutional claim forms, there are two main types used by institutional providers – electronic and paper.

The most common electronic form nowadays is the 837 Institutional (837I), which follows a standard format for sending claims electronically. This allows for faster processing compared to paper. The old paper standard was the UB-04, also called the CMS-1450. It’s still used sometimes if the provider can’t submit electronically.

The 837I is best for routine claims that don’t need attachments or extra documentation. It’s fast and efficient. The UB-04 is good for claims that are out of the ordinary or need paperwork included. It’s a bit slower but works when electronic isn’t an option.

Both serve a purpose – one for typical claims sent online, one for special cases submitted by mail. But in general, electronic 837 Institutional claims are the new normal for institutional providers.

2). Professional Claim Form

Professional claim forms refer to the bills submitted to insurance companies by independent doctors, therapists, and other licensed healthcare providers. The professional providers themselves are the physicians, physical therapists, psychologists and so on who work directly with patients. To get paid for their services, they fill out professional claim forms with information like the dates of treatment, services provided, and total charges for each patient. The insurance companies then decide how much they will reimburse.

⇉ Types of Professional Claim Forms

When it comes to professional medical claim forms, there are two main types – electronic and paper.

The most common electronic form is the 837 Professional (837P) claim form. This follows the ANSI ASC X12N standard for healthcare transactions, just like its cousin, the 837I institutional form. It allows for efficient, standardized electronic submission of claims data.

The old school paper claim form is the CMS-1500. This has traditionally been used by doctors, clinics, and other professional providers to submit claims by mail. It contains all the required data fields and codes needed for reimbursement.

The 837P is ideal for practices with a high volume of claims. It’s fast, accurate, and integrates directly into practice management and billing systems. The CMS-1500 is the way to go for providers who prefer paper or have a low claim volume. While one is pixels and one is pulp, both serve the same essential purpose – getting providers paid for services rendered.

3). Dental Claim Form

In the United States, when a patient visits their dentist for any treatment, the dentist will submit a claim to the patient’s insurance provider for the services rendered. This is done using a standard form called a Dental Claim Form. Unlike a medical claim form, a dental claim form is specifically designed to provide details about dental procedures and care.

The goal of a Dental Claim Form is simple: to allow dentists to bill dental insurance companies so patients are not burdened with paying the full cost out of pocket and that the dentist gets reimbursed for his services.

The Dental Claim Form provides details such as the patient’s name and insurance details, the date of service, descriptions of the procedures performed, the charges for each service, and the total amount due. The dentist submits the claim form to the patient’s insurance provider. The insurance provider then processes the claim and pays their share of the cost, while the patient pays any remaining amount as required by their insurance plan.

Without dental claim forms, dentists would have significant difficulties receiving payment and patients would face much higher out-of-pocket costs.

⇉ Types of Dental Claim Forms

There exist two primary types of forms utilized for submitting dental insurance claims.

The first is referred to as the ADA Dental Claim Form J400. This standardized form, created by the American Dental Association, is employed when a patient requires dental treatment and their dentist needs to bill the insurance provider to receive reimbursement for services rendered.

The specifics of the treatment, including procedures done and their associated fees, are documented on the form which is then forwarded to the insurance company by either mail or electronic means.

The second type of claim form is designated as the 837D. This form is also used to report dental treatments and request payment from insurance companies. However, the 837D is in an electronic format following the HIPAA standard.

Dentists enter the required patient and treatment information into their practice management software which then generates the electronic 837D claim form. This is most often transmitted directly to insurance providers for processing the reimbursement.

To summarize, the ADA Dental Claim Form J400 is a paper form used for basic dental insurance claims while the 837D is an electronic form serving the same purpose but in a digital format consistent with HIPAA regulations.

The J400 continues to be accepted by many insurance companies but the 837D is becoming more widely utilized due to its efficiency and standardization. Both fulfill the necessary task of communicating to insurers the specifics of dental care provided so that dentists can be properly reimbursed.

Anatomy of Medical Claim Forms 

Each form has these essential sections: 

• Patient Information [Demographics like name, date of birth, and insurance ID].
• Provider Information [Physician  or facility details].
• Procedure Information [Diagnosis codes and details about the service provided].
• Charges [The cost of the service(s)].
• Insurance Information [Your insurance details and policy number].

The Key Attributes of a Medical Claim Form

➤ When it comes to processing medical claims, there’s a step where the system automatically matches procedure codes. If the codes don’t match up, a fatal non-match indicator is triggered. But don’t worry, this indicator can’t be used to enter a fake code on the claims page or send one through the claims update integration point.

➤ Every claim form belongs to a specific type of insurance. The type of insurance determines what part of the business it is for, like car insurance, health insurance, or travel insurance.

➤ Each claim form can only belong to one claim form type. We use claim form types in many of our rules to refer to groups of claim forms.

➤ A good example for health insurance in the US is that claim forms represent the different ways a claim can be submitted. This includes electronic formats 837P, 837I and 837D and paper forms UB04, CMS1500 and J400.

➤ When it comes to two specific claim forms, the UB04 and the 837I, they’re both considered institutional claims. This means they’re treated the same way for adjudication purposes, regardless of whether they were submitted electronically or through the mail. In other words, both forms would fall under the umbrella of the “Institutional” claim form type.

Top 10 Tips to Fill Out Medical Claim Forms

1). Check that you have the correct patient and insurance information. Make sure the patient’s name, date of birth, insurance ID number and group number are all accurate. Double check the insurance payer’s mailing address for claims. One small error can lead to denied or delayed payments.

2). Use the proper claim form. Choose between the CMS 1500 or UB04 form depending on the type of provider you are. Make sure you are using the most up to date version of the form to avoid rejections.

3). Record the proper diagnosis and procedure codes. Check that the ICD-11 diagnosis codes and CPT procedure codes you’ve selected accurately reflect the services provided. Code correctly the first time to avoid delays.

4). Include documentation to support your claim. Attach operative reports, progress notes, and other records to provide evidence for the medical necessity of the services billed. Lack of documentation is a leading cause of claim denials.

5). Check that your fees are within the allowed amount. Bill your usual and customary fees unless the insurance payer has a pre-negotiated rate. Charging above the allowed amount will result in payment delays and unhappy patients.

6). Obtain preauthorization when required. Some insurance plans require preauthorization for hospital admissions, procedures, and other services. Failure to obtain preauthorization can result in denied claims.

7). Meet timely filing deadlines. Submit claims within 30-90 days of the date of service depending on the insurance payer’s requirements. Late submissions will lead to denied claims.

8). Submit electronically whenever possible. Electronic submissions through a clearinghouse help to reduce errors and allow for faster processing and payment. Only use paper claim forms when electronic filing is not an option.

9). Follow up on unpaid claims. Check the status of unpaid claims after 30 days. Look for denials or requests for additional information. Resubmit or appeal denied claims as needed. Don’t leave money on the table due to lack of follow up!

10). Keep good records. Maintain copies of all claims, correspondence, and remittance advice for reference. Well-organized records make it easier to track the status of claims, identify trends, and resolve any issues.

Don’t know how to choose the correct claim form and fill it? Let Us Help You!

For healthcare providers, claim forms are a necessary evil. Choosing the right form, CMS 1500 or UB-04, is just the beginning. Enter one wrong code or missed signature and your reimbursement could be delayed or denied. Not to mention the penalties you could face for inaccurate claims.

Stop struggling with claim forms. BellMedEx is here to help! Our medical billing specialists thrive on paperwork that makes most providers cringe. We’ll ensure your claims are filled out completely, correctly, and ready for prompt reimbursement. One less headache for your practice.

Trust us to handle the confusing claim forms. You handle the critical patient care. Contact us today so your claims sail through cleanly.

Schedule a FREE Consultation Today

Any healthcare provider filling out false or fraudulent information in the claim for payment is guilty of a crime and may be subject to heavy fines and confinement in prison. It also damages your healthcare facility’s reputation in the area, causing the revenue to drop as well.

That’s why it’s important to fully understand the UB-04 claim form. We’ll provide healthcare providers with the knowledge and instructions to use the UB-04 claim form and ensure proper reimbursement for services rendered.

About UB-04 Claim Form

The UB-04 form, previously called the CMS-1450 form, is the standard claim form used by an institutional healthcare provider to submit inpatient and outpatient medical claims for reimbursement from insurance companies when a provider qualifies for a waiver from the ASCA requirement for electronic submission of claims.

Key Points about UB-04 Claim Form:

• The National Uniform Billing Committee (NUBC) oversees the development and updates of the UB-04 form, ensuring its consistency and compliance.
• The purpose of the UB-04 claim form is to maintain the official record of all reimbursable care received by patients, allowing healthcare providers to bill Medicare, Medicaid, and other prayers for inpatient and outpatient services.
• The UB-04 form is widely adopted in healthcare. Over 98% of Medicare claims and more than 80% of all institutional claims use the UB-04 form.
• The UB-04 claim form is particularly used by institutional providers like hospitals, nursing homes, rural health clinics, and rehabilitation centers.
• The UB-04 form includes specific fields or boxes for providers to enter their NPI, facilitating accurate identification and streamlined communication with payers.

History

Back in the 1980s, the UB92 form was the go-to for hospital billing. But as time passed, it became outdated, and in 2007, the UB04 form stepped in to fix things. Developed by the NUBC and CMS, it offered more space for details, additional data fields, and a much easier-to-use format. Today, the UB04 is the standard for billing hospital services, making things smoother for both healthcare providers and insurance companies.

Importance and Usage

Treating patients is difficult work. Getting paid properly for treating those patients shouldn’t have to be. That’s the idea behind the UB-04 form.

It’s the standard billing document hospitals and clinics submit to insurance companies to receive reimbursement for inpatient and outpatient care they’ve already provided.

A well-crafted UB-04 tells the insurance companies in clear terms exactly which services and treatments were delivered to which patients, and the precise costs involved.

When healthcare providers take care to fully and accurately complete the UB-04, it streamlines the payment process and reduces the likelihood of denied or delayed claims.

The UB-04 aims to make medical billing more efficient so healthcare providers can focus on healthcare. After all, they got into medicine to treat patients, not to battle with insurance companies over payment. The UB-04 form helps them do a bit less of the latter.

Have a look at these points showing the importance of UB-04 in medical billing:

1). Streamlines communication between the provider and the insurance payer.

The UB-04 claim form provides a standardized format and medical codes (ICD-10 for diagnoses and CPT/HCPCS for procedures) for capturing and communicating billing information, ensuring clarity and efficiency.

For example, if a patient has a heart attack, the doctor will record the code for acute myocardial infarction, the proper name for a heart attack. They’ll also list codes for any procedures like CPR, medications, or time in intensive care. The insurance people see the codes and understand right off what happened and how the doctor handled it. Without the UB-04, the patient’s claim would be a mess of long descriptions and illegible handwriting. The UB-04 form makes it all as simple and orderly as possible.

2). Ensures the provider is accurately reimbursed for their services to the patient.

Accurately documenting services and charges in the UB-04 form helps providers receive the correct payment for their healthcare services.

For instance, a woman comes to see the doctor with a nasty cough that won’t go away. He listens to her lungs, checks her temperature, maybe does an X-ray. He’ll write out each step he took, and how much it set her back.

‘Examined patient, noted congested lungs and elevated temperature. Took chest X-ray to check for pneumonia. Total cost: $250.’

He’s got to write that down, along with the cost of the X-ray and painkillers and such. That way the insurance knows the patient owes the doctor for a cough treatment, not just a routine checkup.

If the doctor is careful and clear, the insurance will see he did right by her, and pay up. A doctor’s got overheads to meet, after all. Keeping good records and charging fair via the UB-04 form ensures the whole operation stays afloat.

3). Reduces claim denials.

The UB-04 lowers the number of bills insurance companies refuse by clearly showing the treatment, cost, and medical terms.

For example, imagine a man hospitalized with chest pain. Tests show two blocked heart arteries needing bypass surgery. Surgeons perform coronary artery bypass graft, or CABG. The hospital sends a UB-04 to the insurance company with codes for tests, surgery, drugs, and stay. The insurance folks understand CABG and medical terms on the standardized form, so they pay the claim.

4). Enables reimbursement through claim submission.

By reporting the specifics of each patient visit and the associated fees, the UB-04 form enables hospitals and physicians to receive payment for their services so they can keep the lights on, pay their staff, and continue helping the sick and injured. For healthcare organizations, reimbursement is lifeblood, and the unassuming UB-04 form provides transfusion.

5). Helps identify all healthcare professionals involved in a patient’s treatment.

The UB-04 is important because it lets the hospital tell the insurance company all the doctors, nurses, and staff that cared for the patient. That way, the insurance company knows exactly what they need to pay for. The form has boxes for the hospital to write the names and details of all the people involved in the patient’s treatment. So at the end of the stay, the insurance company can see the whole picture and reimburse the hospital properly. The hospital can then pay the staff accordingly. It’s a simple form that helps keep things clear and fair.

Who Uses the UB-04 Claim Form for Billing the Medical Services?

Institutional healthcare providers, such as hospitals, nursing facilities, dialysis centers, home health agencies, hospice providers, PRTFs, swing-bed facilities, all use the UB-04 claim form to bill inpatient and outpatient services and submit claims for reimbursement to insurance companies and other payers.

Let us detail down these providers who will use the UB-04 claim form for billing the healthcare services.

➜ Hospitals — General hospitals, children’s hospitals, and specialty hospitals all use the UB-04 form to bill for inpatient and outpatient services, including surgeries, diagnostic tests, and other medical treatments.

➜ Healthcare Facilities — Skilled nursing facilities (SNFs), long-term care facilities (LTCFs), and other nursing homes also use the UB-04 form to bill for daily care, therapy services, and other related healthcare services provided to residents.

➜ Dialysis Centers — Facilities offering hemodialysis and peritoneal dialysis services rely on the UB-04 claim form to bill for these specialized treatments.

➜ Home Health Agencies — Agencies providing in-home healthcare services, such as skilled nursing care, physical therapy, and occupational therapy, also use the UB-04 form to bill for these services.

➜ Hospice Providers — Organizations offering end-of-life care and support to terminally ill patients utilize the UB-04 form to bill for hospice services.

➜ Psychiatric Residential Treatment Facilities (PRTFs) — Facilities providing residential treatment for individuals with mental health conditions use the UB-04 form to bill for services such as therapy, medication management, and daily living support.

➜ Swing-Bed Facilities — Hospitals with designated swing beds that can be used for both acute and long-term care utilize the UB-04 form to bill for both types of services.

Where is the UB-04 Claim Form Used?

The UB-04 claim form plays a crucial role in the healthcare billing process, serving as the standardized format for institutional healthcare providers to submit claims for reimbursement to various entities, including:

• Commercial Insurance Companies
• Medicare and Medicaid
• Other Government Payers
• Workers’ Compensation Programs
• Self-Pay Patients

Commercial Insurance Companies

Private health insurance companies rely on the UB-04 form to process claims for services provided to their insured patients by institutional providers. 

Medicare and Medicaid

These government programs utilize the UB-04 form for claims submitted by hospitals, nursing homes, and other institutional providers for services rendered to eligible beneficiaries.

Other Government Payers

UB-04 Claim Form is used by various state and federal government programs beyond Medicare and Medicaid for claims processing, including military healthcare programs, specific disease management programs, and more. 

Workers’ Compensation Programs

When an employee is injured on the job, the UB-04 form is often used to submit claims for services provided by institutional healthcare facilities to the relevant workers’ compensation program.

Self-Pay Patients

Even for patients without health insurance, the UB-04 form can be used to document and bill for services rendered, helping the healthcare facility collect payment directly from the patient.

UB-04 Claim Form Instructions

The UB-04 form has a specific structure designed to efficiently capture and communicate billing information for institutional healthcare providers. Complete each section accurately to ensure smooth claim processing and timely reimbursement.

Here’s a detailed breakdown of how to fill it out:

FAQs About UB-04 Claim Form

What is the difference between CMS 1500 and UB-04 claim forms?

The key difference lies in the types of providers using each form. CMS 1500 (HCFA-1500) is used by physicians and other individual healthcare providers to bill for their professional services. And UB-04 is used by institutional facilities to bill for services provided within the facility.

How many boxes or fields, blocks, or form locators (FLs) are in the UB-04 claim form?

The UB-04 claim form has 81 individual fields, boxes, or blocks, also known as Form Locators (FLs). Each FL has a specific purpose and requires unique information to be filled in for accurate claim processing. Understanding each FL is crucial to ensure smooth reimbursement.

How to get UB-04 form from hospital?

Hospitals typically don’t provide the UB-04 form directly to patients. The UB-04 form is used by the hospital itself to bill insurance companies for services provided to patients.

However, you can get the UB-04 form in the following ways:

• Download it online: You can find blank UB-04 forms on the websites of healthcare organizations and government agencies.
• Contact your insurance company: Some insurance companies also provide pre-filled UB-04 forms for their members.
• Request it from the hospital’s billing department: While not common, you can contact the hospital’s billing department and inquire about obtaining a copy of your UB-04 form.

Do You Find It Hectic To Fill and Complete The UB-04 Form? Get Immediate Help Here!

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We grasp the complexities of the UB-04 form and insurance procedures to guarantee your claims are submitted correctly the first time. Our experienced staff treats each claim with care and urgency to accelerate your reimbursement.

Why deal with the hassle yourself? Our company’s billing service allows you to offload the responsibility and headaches that come with claim filing. Choose us as your partner in healthcare administration.

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