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UB-04 Completion: Outpatient Services - Medi-Cal Billing Instructions, Exams of Nursing

Instructions for completing the UB-04 claim form for outpatient services under Medi-Cal. It covers topics such as facility type codes, form items descriptions, organ donors, Medicare status codes, occurrence codes and dates, value codes and amounts, modifiers, and payer information. It also includes a legend explaining symbols used in the document.

What you will learn

  • What codes and dates should be entered in Boxes 31 thru 34 if the accident or injury was employment related?
  • What information is required to complete the UB-04 claim form for outpatient services under Medi-Cal?
  • What Medicare status codes are required for Charpentier claims?

Typology: Exams

2021/2022

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Part 2 UB-04 Completion: Outpatient Services
UB-04 Completion: Outpatient Services
Page updated: September 2020
The UB-04 claim form is used to submit claims for outpatient services by institutional
facilities (for example, outpatient departments, Rural Health Clinics and chronic dialysis
centers). See UB-04 Completion: Inpatient Services in the Part 2 Inpatient Services Manual
for billing instructions for services rendered to a registered hospital inpatient.
If the patient is treated as an outpatient in a hospital different from the one in which the
patient is registered, the services must be billed by the treating hospital using the UB-04
claim form with the appropriate facility type code (which is the first two digits in the Type of
Bill field [Box 4]) for the outpatient facility.
Most claims for outpatient services can also be submitted through Computer Media Claims
(CMC). For CMC ordering and enrollment information, refer to the CMC section in the Part 1
manual.
For additional billing information, refer to the UB-04 Special Billing Instructions for Outpatient
Services, UB-04 Submission and Timeliness Instructions and UB-04 Tips for Billing:
Outpatient Services sections in this manual.
LEA Providers:
Timeliness limitations differ for Local Educational Agency (LEA) providers. LEA providers
refer to the Local Educational Agency (LEA) Billing and Reimbursement Overview section.
For crossover billing information, refer to the Medicare/Medi-Cal Crossover Claims:
Outpatient Services and Medicare/Medi-Cal Crossover Claims: Outpatient Services Billing
Examples.
Medi-Cal cannot process credits or adjustments on the UB-04 form. Refer to the CIF
Completion and CIF Special Billing Instructions for Outpatient Services sections in the
appropriate Part 2 manual for information about claim adjustments.
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Download UB-04 Completion: Outpatient Services - Medi-Cal Billing Instructions and more Exams Nursing in PDF only on Docsity!

UB-04 Completion: Outpatient Services

Page updated: September 2020

The UB- 04 claim form is used to submit claims for outpatient services by institutional

facilities (for example, outpatient departments, Rural Health Clinics and chronic dialysis

centers). See UB-04 Completion: Inpatient Services in the Part 2 Inpatient Services Manual

for billing instructions for services rendered to a registered hospital inpatient.

If the patient is treated as an outpatient in a hospital different from the one in which the

patient is registered, the services must be billed by the treating hospital using the UB- 04

claim form with the appropriate facility type code (which is the first two digits in the Type of

Bill field [Box 4]) for the outpatient facility.

Most claims for outpatient services can also be submitted through Computer Media Claims

(CMC). For CMC ordering and enrollment information, refer to the CMC section in the Part 1

manual.

For additional billing information, refer to the UB-04 Special Billing Instructions for Outpatient

Services, UB-04 Submission and Timeliness Instructions and UB- 04 Tips for Billing:

Outpatient Services sections in this manual.

LEA Providers:

Timeliness limitations differ for Local Educational Agency (LEA) providers. LEA providers

refer to the Local Educational Agency (LEA) Billing and Reimbursement Overview section.

For crossover billing information, refer to the Medicare/Medi-Cal Crossover Claims:

Outpatient Services and Medicare/Medi-Cal Crossover Claims: Outpatient Services Billing

Examples.

Medi-Cal cannot process credits or adjustments on the UB- 04 form. Refer to the CIF

Completion and CIF Special Billing Instructions for Outpatient Services sections in the

appropriate Part 2 manual for information about claim adjustments.

Page updated: September 2020

Figure 1: Medi-Cal Required Fields for Outpatient UB- 04 Claims

Page updated: October 2021

Table of Facility Type Codes

Code Facility Type

Hospital, Outpatient

Hospital, Laboratory Services Provided to Non-Patients

Skilled Nursing, Outpatient

Home Health Services Under a Plan of Treatment

Home Health Services, Not Under a Plan of Treatment

43 Religious Non-Medical Health Care Institutions, Outpatient Services

Clinic, Rural

Clinic, Hospital Based or Independent Renal Dialysis Center

Clinic, Freestanding

Clinic, Outpatient Rehabilitation Facility (ORF)

Clinic, Comprehensive Outpatient Rehabilitation Facility (CORF)

Clinic, Community Mental Health Center

77 Federally Qualified Health Center (FQHC)

78 Licensed Freestanding Emergency Medical Facility

Clinic, Other

Specialty Facility, Hospice (non-hospital based)

Specialty Facility, Hospice (hospital based)

Specialty Facility, Ambulatory Surgery Center

Specialty Facility, Freestanding Birthing Center

85 ‹‹Specialty Facility, Critical Access Hospital››

87 Specialty Facility, Freestanding Non-Residential Opioid Treatment Program

Specialty Facility, Other

Notes: Only one facility type may be billed on each claim. Outpatient services not logically

compatible with the facility type identified on the claim must be billed on a separate

claim.

For subacute services, specify the appropriate Place of Service and use modifier U2.

Page updated: October 2021

Table of Form Items Descriptions (Continued)

Item Description

  1. Type of bill (continued). Clinics and outpatient hospitals use one of the following

codes as the first two digits of the three-character type of bill code:

Table of Facility Type Codes by Provider Type

Provider Type Facility Type

AIDS Waiver Agency ‹‹ 13, 32, 34 79

Chronic Dialysis Clinic 72

Community Hospital, Outpatient 13

Community Mental Health Clinic 76

Employer/Employee Clinic 79

Exempt from Licensure Clinic 79

Free Clinic 79

Home Health Agency ‹‹ 32, 34

Local Educational Agency 89

Multispecialty Clinic 79

Rehab Clinic 74

Rehab Clinic (Comprehensive) 75

Rural Health Clinic 71

Surgical Clinic 73, 79

Page updated: October 2021

Organ Donors

When submitting a claim for a patient donating an organ to a Medi-Cal recipient, enter the

donor’s name, date of birth and sex in the appropriate boxes. Enter the Medi-Cal recipient’s

name in Box 58 ( Insured’s Name ) and enter “11” (donor) in Box 59 ( Patient’s Relationship to

Insured).

Table of Form Items Descriptions (Continued)

Item Description

9A thru

E

Patient address. Not required by Medi-Cal.

  1. Birthdate. Enter the patient’s date of birth in an eight-digit MMDDYYYY (Month,

Day, Year) format (for example, September 16, 1967 = 09161967). If the

recipient’s full date of birth is not available, enter the year preceded by 0101.

(For newborns and organ donors, see Item 8B.)

Page updated: October 2021

Table of Form Items Descriptions (Continued)

Item Description

  1. Sex. Use the capital letter “M” for male, or “F” for female. (For newborns and

organ donors, see Item 8B on a previous page.)

  1. Admission date. Not required by Medi-Cal.
  2. Admission hour. Not required by Medi-Cal.
  3. Admission type. ‹‹Not required by Medi-Cal.››
  4. Admission source. Not required by Medi-Cal.
  5. Discharge hour. Not required by Medi-Cal.
  6. Status. Not required by Medi-Cal.

18 thru

Condition codes. Condition codes are used to identify conditions relating to

this claim that may affect payer processing.

Although the Medi-Cal claims processing system only recognizes the condition

codes on the following pages, providers may include codes accepted by other

payers. The claims processing system ignores all codes not applicable to

Medi-Cal.

Condition codes should be entered from left to right in numeric-alpha sequence

starting with the lowest value. For example, if billing for three condition codes,

“A1”, “80” and “82”, enter “80” in Box 18, “82” in Box 19 and “A1” in Box 20.

Applicable Medi-Cal codes are:

Other Coverage: Enter code “80” if recipient has Other Health Coverage

(OHC). OHC includes insurance carriers as well as Prepaid Health Plans

(PHPs) and Health Maintenance Organizations (HMOs) that provide any of the

recipient’s health care needs. Eligibility under Medicare or a Medi-Cal

managed care plan is not considered other coverage and is identified

separately.

Medi-Cal policy requires that, with certain exceptions, providers must bill the

recipient’s other health insurance prior to billing Medi-Cal. (For details about

OHC, refer to the Other Health Coverage (OHC) Guidelines for Billing section

in the Part 1 manual.)

Page updated: September 2020

Table of Form Items Descriptions (Continued)

Item Description

18 thru

Condition codes (continued). Medicare Status: Medicare status codes are

required for Charpentier claims. In all other circumstances, these codes are

optional; therefore, providers may leave this area of the Condition Codes fields

(Boxes 18 thru 24) blank. The Medicare status codes are:

‹‹Table of Medicare Status Codes and Descriptions››

Code Description

Y0 Under 65, does not have Medicare coverage

Y
  • Benefits exhausted
Y
  • Utilization committee denial or physician non-certification
Y
  • No prior hospital stay
Y
  • Facility denial
Y
  • Non-eligible provider
Y
  • Non-eligible recipient
Y
  • Medicare benefits denied or cut short by Medicare intermediary

Y8 Non-covered services

Y 9
  • PSRO denial
Z
  • Medi/Medi Charpentier: Benefit Limitations
Z
  • Medi/Medi Charpentier: Rates Limitations
Z
  • Medi/Medi Charpentier: Both Rates and Benefit Limitations

Table of Form Items Descriptions (Continued)

Item Description

25 thru

Condition codes. The Medi-Cal claims processing system only recognizes

condition codes entered in Boxes 18 thru 24.

  1. Acdt state. Not required by Medi-Cal.
  2. Unlabeled. Not required by Medi-Cal.

Page updated: September 2020

Table of Form Items Descriptions (Continued)

Item Description

31 thru

34A thru

B.

Occurrence codes and dates. Occurrence codes and dates are used to

identify significant events relating to a claim that may affect payer processing.

Occurrence codes and dates should be entered from left to right, top to bottom

in numeric-alpha sequence starting with the lowest value. For example, if billing

for two occurrence codes “24” (accepted by another payer) and ”05”

(accident/no medical or liability coverage), enter “05” in Box 31A and “24” in

Box 32A. Refer to Figure 2 below.

Figure 2. Occurrence Codes Example.

Table of Form Items Descriptions (Continued)

Item Description

31 thru

34A thru

B.

Occurrence codes and dates. (continued). Although the Medi-Cal claims

processing system will only recognize the following codes, providers may

include codes and dates billed to other payers in Boxes 31 thru 34. The claims

processing system will ignore all codes not applicable to Medi-Cal.

Applicable Medi-Cal codes are:

Enter code “04” (accident/employment-related) in Boxes 31 through 34 if the

accident or injury was employment related. Enter one of the following codes if

the accident or injury was non-employment related:

Table of Occurrence Codes and Descriptions

Code Description

01 Accident/medical coverage

02 No fault insurance involved – including auto accident/other

03 Accident/tort liability

05 Accident/no medical or liability coverage

06 Crime victim

In six-digit MMDDYY (Month, Day, Year) format, enter the date of accident/injury in the

corresponding box.

Page updated: September 2020

Table of Form Items Descriptions (Continued)

Item Description

39 thru

41A thru

D.

Value codes and amount. Patient’s Share of Cost. Value codes and

amounts should be entered from left to right, top to bottom in numeric-alpha

sequence, starting with the lowest value. For example, if billing for two value

codes “30” (accepted by another payer) and “23” (accepted by Medi-Cal), enter

“23” in Box 39A and “30” in Box 40A. ( See Figure 3 below.)

Value codes and amounts are used to relate amounts to data elements

necessary to process the claim. Although the Medi-Cal claims processing

system only recognizes code “23,” providers may include codes and dates

billed to other payers in Boxes 39 thru 41. The claims processing system will

ignore all codes not applicable to Medi-Cal.

Enter code “23” and the amount of the patient’s Share of Cost for the

procedure or service, if applicable. Do not enter a decimal point (.), dollar sign

($), positive (+) or negative (-) sign. Enter full dollar amount and cents, even if

the amount is even (for example, if billing for $100, enter 10000 not 100). For

more information about Share of Cost, see the Share of Cost: UB-04 for

Outpatient Services section in this manual.

Figure 3: Value Codes Example.

Page updated: September 2020

Table of Form Items Descriptions (Continued)

Item Description

39 thru

41A thru

D.

Value codes and amount. Patient’s Share of Cost (continued).

  1. Revenue code. Revenue codes are required (for instance, for organ

procurement) for select outpatient billing. Specific instructions are included in

select provider manual sections.

Total Charges: Enter “001” on line 23, and enter the total amount on line 23,

field 47.

  1. Description. This field will help you separate and identify the descriptions of

each service. The description must identify the particular service code

indicated in the HCPCS/Rate/HIPPS Code field (Box 44). For more

information, refer to the CPT

®

code book. This field is optional except when

billing for physician-administered drugs.

Entering the National Drug Code (NDC) for Physician-Administered

Drugs : Enter the product ID qualifier N4 followed by the 11-digit NDC (no

spaces or hyphens). Directly following the last digit of the NDC (no space),

enter the two-character unit of measure qualifier followed by the numeric

quantity. Refer to the Physician-Administered Drugs – NDC: UB-04 Billing

Instructions section in this manual for more information.

Notes : Unit of measure and numeric quantity are optional. Absence of these

two elements will not result in claim denial.

If there are multiple pages of the claim, enter the page numbers on line 23 in

this field.

Page updated: September 2020

Table of Form Items Descriptions (Continued)

Item Description

  1. Service date. Enter the date the service was rendered in six-digit, MMDDYY

(Month, Day, Year) format, for example, June 24, 20 20 = 062420.

‘From-Through’ Billing

For “From-Through” billing instructions, refer to the UB-04 Special Billing Instructions for

Outpatient Services section in this manual.

‹‹Table of Form Items Descriptions (Continued)››

Item Description

  1. Service units. Enter the actual number of times a single procedure or item was

provided for the date of service. Medi-Cal only allows two digits in this field. If

billing for more than 99, divide the units on two or more lines.

  1. Total charges. In full dollar amount, enter the usual and customary fee for the

service billed. Do not enter a decimal point (.) or dollar sign ($). Enter full dollar

amount and cents, even if the amount is even (for example, if billing for $100,

enter 10000 not 100). If an item is a taxable medical supply, include the

applicable state and county sales tax.

Note : Medi-Cal cannot process credits or adjustments on the UB- 04 form.

Refer to the CIF Completion and CIF Special Billing Instructions for

Outpatient Services sections in the appropriate Part 2 manual for

information regarding claim adjustments.

Enter the “Total Charge” for all services on line 23. Enter code 001 in Revenue

Code field (Box 42) to indicate that this is the total charge line (refer to Item 42

on a preceding page).

  1. Non-covered charges. Not required by Medi-Cal.
  2. Unlabeled. Not required by Medi-Cal.

Note : Providers may enter up to 22 lines of detail data (Items 42 thru 49). It is

also acceptable to skip lines.

To delete a line, mark through the boxes as shown in Figure 5. Be sure to draw

a thin line through the entire detail line using a blue or black ballpoint pen.

Figure 5: Line Deletion Example for UB- 04 Claim.

Page updated: September 2020

Table of Form Items Descriptions (Continued)

Item Description

50A thru

C.

Payer name. Enter “O/P MEDI-CAL” to indicate the type of claim and payer.

Use capital letters only. Refer to Figure 6.

When completing Boxes 50 thru 65 (excluding Box 56) enter all information

related to the payer on the same line (for example, Line A, B or C) in order of

payment (Line A: other insurance, Line B: Medicare, Line C: Medi-Cal). Do not

enter information on Lines A and B for other insurance or Medicare if payment

was denied by these carriers.

When billing other insurance, the other insurance is entered on Line A of

Box 50, with the amount paid by Other Coverage on Line A of Box 54 ( Prior

Payments ). All information related to the Medi-Cal billing is entered on Line B

of these boxes. Be sure to enter the corresponding prior payments on the

correct line.

If Medi-Cal is the only payer billed, all information in Boxes 50 thru 65

(excluding Box 56) should be entered on Line A.

Reminder : If the recipient has Other Health Coverage, the insurance carrier

must be billed prior to billing Medi-Cal.

Figure 6: Payer Name Example for UB- 04 Claim.

Page updated: September 2020

Table of Form Items Descriptions (Continued)

Item Description

  1. NPI. Enter the National Provider Identifier (NPI).

57A thru

C.

Other (billing) provider ID (Used by atypical providers only). Enter the

Medi-Cal provider number, corresponding to information on lines A, B or C.

Note : Required prior to the mandated NPI implementation date when an

additional identification number is necessary to identify the provider, or

if on and after the mandated NPI implementation, the NPI is not used in

Box 56 and an identification number other than the NPI is necessary

for the receiver to identify the provider.

58A thru

C.

Insured’s name. If billing for an infant using the mother’s ID or for an organ

donor, enter the Medi-Cal recipient’s name here and the patient’s relationship

to the Medi-Cal recipient in Box 59 ( Patient’s Relationship to Insured ). See

Item 8B on a previous page. This box is not required by Medi-Cal except

under the two circumstances listed in Item 8B.

59A thru

C.

Patient’s relationship to insured. If billing for an infant using the mother’s ID

or for an organ donor, enter the code indicating the patient’s relationship to

the Medi-Cal recipient (for example, “03” [child] or “11” [donor]). See Item 8B

on a previous page. This box is not required by Medi-Cal except under the

two circumstances listed in Item 8B.

60A thru

C.

Insured’s unique ID. Enter the 14-character recipient ID number as it

appears on the Benefits Identification Card (BIC) or paper Medi-Cal ID card.

Note : Medi-Cal does not accept Medicare ID Numbers.

Page updated: September 2020

Newborn Infant

When submitting a claim for a newborn infant for the month of birth or the following month,

enter the mother’s ID number in this field. (For more information, see Item 8B on a previous

page.)

Table of Form Items Descriptions (Continued)

Item Description

61A thru

C.

Group name. Not required by Medi-Cal.

62A thru

C.

Insurance group number. Not required by Medi-Cal.

63A thru

C.

Treatment authorization codes. For services requiring a Treatment

Authorization Request (TAR), enter the 11-digit TAR Control Number. It is not

necessary to attach a copy of the TAR to the claim. Recipient information on

the claim must match the TAR. Multiple claims must be submitted for services

that have more than one TAR. Only one TAR Control Number can cover the

services billed on any one claim.

Note : TAR and non-TAR procedures should not be combined on the same

claim.