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Knowledge Base > Setup > Payer Setup > UB-04 Settings

Change UB-04 Settings

The UB-04 tab is used to format Institutional Claims; the CMS-1500 is used for Professional Claims. The UB-04 form is used by Outpatient Rehabilitation Facilities, CORF's, hospitals and other institutions. The CMS-1500 is typically used for Physical Therapists in Independent Practice (PTIPs). Most payers follow standard settings, such as NPI, for UB-04 settings and CMS-1500, however, there are some payers who require legacy identifiers (such as UPINs and payer specific provider numbers) as well as other non-standard settings. Understanding your credentialing status and specific payer requirements is crucial in setting up billing forms correctly. Most payers post instructions on their website and their claims representatives should be able to provide the proper settings for both paper and electronic requirements.

Tip: Download the latest CMS Manual System UB04_Instructions.pdf.

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UB-04 Default Settings

The default settings are used by payers who follow the standardized UB-04 settings. However, be sure to review selections for each setting in the NPI column and make any necessary changes. The Legacy ID column is only used if the payer requires legacy identification. Changes to the default settings are typically only made if the payer has specific non-standard requirements.

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Edit UB-04 Settings
  1. In the Edit menu, click Payers, click , or press F11. The Edit Payers dialog box appears.
  2. For a new payer, click New Payer. For an existing payer, select the payer from the Payer list. Refer to Add or Edit Basic Payer Information to learn about adding new payers.
  3. Click the UB-04 tab.
  4. Verify selections for the following areas of the UB-04 tab and make any necessary changes:
  5. Click Save to save changes and close the Edit Payer dialog box.
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Payer UB-04 Settings

The settings on the UB-04 tab specify where information goes on a paper or electronic claim. This topic defines fields in the UB-04 Edit Payer dialog box, and provides instructions to enter information in fields used to populate the UB-04. Before you are ready to bill claims, you must enter settings for each payer. The fields are labeled with the corresponding location on the UB-04 form and EDI file to help guide you through the setup.

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Common Settings

The settings under NPI on the UB-04 tab are for payers that use the current NPI reporting. The Legacy ID is used for payers who follow legacy reporting requirements. Most payers do not use legacy identifiers and will accept claims using the standard settings (see screen shot below). However, Clinicient recommends checking with your payers to ensure proper settings.

Title Functionality
Attending Doctor ID To enter the Attending Provider Identification numbers, click the button, select a referrer, then enter the values in the respective fields. See this article for detailed information on Enter Referral Contact Information.
Service Facility ID

To enter the Service Facility/Clinic Identification numbers, perform the following steps.

  1. From the Settings menu, select Company & Clinic Info or click .The Company Info and Clinic Management dialog displays.
  2. If you have multiple clinics, select one from the Clinic list, then enter the values in the respective fields under the Clinic Billing Info section.
Billing Provider ID

To enter the Billing Provider Identification numbers, perform the following steps.

  1. From the Settings menu, select Company & Clinic Info or click . The Company Info and Clinic Management dialog box appears.
  2. Select the correct setting under Print Billing Provider Legacy ID (block 51, or 57, or both).
  3. If the payer requires a Company (group) Provider ID, perform the following steps.
  4. From the Edit menu, select Payers, press F11, or click . The Edit Payers dialog displays.
  5. Click the Payer field to display a list of payers. Then select a payer from the list.
  6. Click the General Billing Data tab.
  7. Enter your company's provider number in the Group Provider ID field, located in the Company ID #s area.

If the payer requires Clinic Payer Provider #, perform the following steps.

  1. From the Settings menu, click Company and Clinic Info or click . The Company Info and Clinic Management dialog displays.
  2. Click the Clinic field to display a list of payers. Then select a clinic from the list.
  3. In the Clinic Provider Numbers area, click Add to add a new row to the table.
  4. Click the Insurance Plans field and click the arrow to display a list of insurance plans.
  5. Select an insurance plan from the list.
  6. Enter the clinic provider number in the Clinic Provider # field.
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Charge Modifiers

Title Functionality
Include modifiers in print and EDI output

Modifiers are recorded with each charge. They can be added:

  • By the therapist when preparing documentation
  • Automatically, based on billing rules
  • By the Billing group when editing or adding charges

If this option is checked, modifiers are included in the claim.

Add discipline modifiers (GP, GO, GN)

Discipline modifiers are automatically added to a charge when this check box is selected. They indicate the discipline for the charge:

  • GP = Physical Therapy
  • GO = Occupational Therapy
  • GN = Speech Therapy

Typically Medicare requires discipline modifiers. However, Clinicient recommends checking with payers to ensure proper settings.
Always add this modifier Used in rare circumstances on some payers. Entering a modifier in that field will apply the modifier to all codes for that payer.
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Selections

Title Functionality
CORF Offsite

This check box can only be selected if the facility is a Comprehensive Outpatient Rehab Facility (CORF).

To set up a facility as a CORF, perform the following steps.

  1. From the Settings menu, select Company & Clinic Info or click . The Company Info and Clinic Management dialog displays.
  2. From the Agency Type list, located in the ID Information area of the dialog, select Comprehensive Outpatient Rehab Facility.
CORF services provided offsite If the facility is a CORF, and the service is performed elsewhere (such as in a patient's home), select the CORF services provided offsite check box.
Print Charges
Line-By-Line Use if the payer requires each charge for a CPT code to be submitted on a separate line.
Summary Use if the payer requires that the charges for each revenue code are added together and submitted as one item.
Units or Visits
Print Units Use if the payer requires units to be submitted the claim. The system automatically calculates units based on how billing rules are set up. Refer toGeneral Billing Data Tab and How Billing Rules Work for more information.
Print Visits
  • Use if the payer visits to be reported on the claim. For the purposes of the calculation, a visit is considered to be all services provided for a patient in a discipline for one day.
    		•
    ICD Version Select the number that corresponds to the ICD Version used by your clinic.
    Remarks
    Print Remarks

    To specify remarks by patient case that will display on the UB-04 forms and electronic claims, perform the following steps.

    1. From the Edit menu, select Clients, press F9, or click . The Client Editor dialog displays.
    2. Click the Name field to display a list of clients. Then select a client from the list.
    3. Click the Additional Claim Info tab.
    4. In the Claim Remarks area, click Add to add a new row.
    5. In the Start Date field, enter...
    6. In the End Date field, enter...
    7. In the Discipline field, enter...
    8. In the Remarks field, enter your claim remarks. The remarks that you enter are included with the claim.

    If you do not enter claim remarks as noted above, the comments in the Remarksfield in the UB-04 tab of the Edit Payers dialog are included with the claim.
    Print Facility Address To enter the Clinic/Facility Address, click the Company Info and Clinic Management button. See these articles for detailed information on Company and Clinic Information Set Up.
    Fed Tax No.

    Select whether you want to use the clinic or company tax identification number. For more information, see Company and Clinic Setup.

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    Advanced Selections

    Title Functionality
    Referring MD Ref #
    Doctor Provided Number

    Uses the same data set up for Attending Doctor ID field on the UB-04 tab. To enter the Attending Provider Identification numbers, perform the following steps.

    1. From the Edit menu, select Contacts, press F9, or click .
    2. Click the Name field to display a list of contacts. Then select a referring provider from the list.
    3. Enter values in the respective fields.
    Agency Provided ID Number

    If the payer requires a Company (group/agency) Provider ID, perform the following steps.

    1. From the Edit menu, select Payers, press F11, or click .
    2. Click the Payer field to display a list of payers. Then select a payer from the list.
    3. Click the General Billing Data tab.
    4. Enter your company's provider number in the Group Provider ID field, located in the Company ID# area.
    Doctor State License Number

    If the payer requires the referring provider's state license number, perform the following steps.

    1. From the Edit menu, select Contacts, press F9, or click .
    2. Click the Name field to display a list of contacts. Then select a referring provider from the list.
    3. Enter the referring provider's license number in the State License # field.
    Block 37 This is a special setting for Indiana Medicaid. Unless the setting applies to this payer, select Leave Blank.
    Block 3b Unless the payer requires this setting, leave it blank.
    Attending Physician If the payer requires this setting, select this check box. Otherwise, leave it blank.
    Include secondary/tertiary COB segments with primary If the payer requires this setting, select this check box. Otherwise, leave it blank.

    Include Admission Date Loop 2300A

    		 Select this check box for Medicare Part A payers.
    Include Principal Procedure Code in Loop 2300 If the payer requires this setting, select this check box. Otherwise, leave it blank.
    Use '18' for Self Relationship Code If the payer requires this setting, select this check box. Otherwise, leave it blank.
    Force 1 Case per Claim If the payer requires this setting, select this check box. Otherwise, leave it blank.
    Include Referring MD Loop 2310C If the payer requires this setting, select this check box. Otherwise, leave it blank.
    Remove Facility Loop 2301E If the payer requires this setting, select this check box. Otherwise, leave it blank.
    Always Include Facility Loop If the payer requires this setting, select this check box. Otherwise, leave it blank.
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    Value Codes

    Title Functionality
    Print Value Codes Select the Print Value Codes check box to enable all of the fields in the Value Codes area of the Edit Payer dialog. Then make check box selections based on specific payer requirements for paper and EDI submission.
    As Primary Make check box selections based on payer requirements.
    As Secondary Make check box selections based on payer requirements. The system calculates these amounts based on claim charges and any payments that have been received.
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    Provider Codes

    Note for Medicare Part A payers: All Provider Codes fields except Block 76 should be set to Leave Blank. Set Block 76 to Referring MD for Medicare Part A payers.

    Title Functionality
    Block 8a Select whether to use the Member ID number or leave this field blank.
    Attending
    Block 76    		 Sets the name of the therapist, referring MD, or primary care physician that is used for these fields.
    Rendering
    Block 77    		 Sets the name of the therapist, referring MD, or primary care physician that is used for these fields. Unless the payer requires this setting, leave it blank.
    Referring
    Block 78    		 Sets the name of the therapist, referring MD, or primary care physician that is used for these fields. Unless the payer requires this setting, leave it blank.
    Block 79 Sets the name of the therapist, referring MD, or primary care physician that is used for these fields. Unless the payer requires this setting, leave it blank.
    Block 81a Sets the name of the therapist, referring MD, or primary care physician that is used for these fields. Unless the payer requires this setting, leave it blank.
    Block 81b Sets the name of the therapist, referring MD, or primary care physician that is used for these fields. Unless the payer requires this setting, leave it blank.

    Important things to remember:

    • If an Attending Physician has been selected in the Advanced Selections, all claims will include the attending physician's name in block 76, and in EDI loop 2310A, regardless of what is selected in the Provider Codes section.
    • If block 76, 77, and 78 have been set to Leave Blank and a Referring MD has been selected for the case, the Referring MD name will print in block 76 as the attending provider, and in EDI loop 2310A, the Attending Provider loop.
    • If the case for a patient is "Self Referred", then nothing will print in Blocks 76, 77, or 78, and nothing will be included in loops 2310A, 2310D, and 2310F in the EDI file, no matter what has been selected.
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    Occurrence Codes

    Title Functionality
    Onset Date

    Select this check box based on specific payer requirements for paper and EDI submission.

    To enter the value for this field, perform the following steps.

    1. From the Edit menu, select Clients, press F9, or click .
    2. Click the Name field to display a list of clients. Then select a client from the list.
    3. Click the Case Information tab.
    4. Enter the onset date in the Onset Date field, located in the Case Information area..
    Date of First Treatment

    Select this check box based on specific payer requirements for paper and EDI submission.

    The system automatically populates this field, based on documentation in the patient's EMR.
    Omit Plans of Care that fall within the date range of the claim

    Select this check box based on specific payer requirements for paper and EDI submission.

    If this check box is selected, the Plan of Care Date (based on the Eval Date, as described above) is only included if it falls on or before the start date of the claim.
    Use MMDDCCYY for printed Occurence Date format

    Select this check box based on specific payer requirements for paper and EDI submission.

     
    Plan of Care Dates

    The system automatically populates this field based on the patient's Plan of Care information in their EMR.

    See Medicare Plan of Care and Progress Report Tracking for detailed information on .
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    Remarks

    To enter information in the Remarks area of the Edit Payer dialog that you want displayed on the UB-04 form and electronic claim, perform the following steps.

    1. Click the Remarks field.
    2. Enter up to 200 characters of information in the field.
    3. Ensure that you have selected Print Remarks in the Remarks field of the Selection area.
    4. Click Save to save your changes.

    Note: If you have entered remarks for the patient case using the procedure above, then these remarks will override any information that is entered in the Remarks area of the Edit Payer dialog.

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    Override Type of Bill

    Digits entered in the text boxes in the Override Type of Bill area of the Edit Payer dialog appear on the UB-04 form, combined with the agency type. The first two characters are the agency type and the last character is the number entered here. The system uses the appropriate digit, based on where the patient is in the Plan of Care. This overrides what the system does automatically, based on specific payer requirements.

    Text boxes:

    • 1 - Admit thru Discharge,
    • 2 - First Claim,
    • 3 - Continuing,
    • 4 - Last Claim.
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    CPT to Revenue Code Mappings

    For certain CPT codes, a payer may want a suffix with a CPT code.

    To add a suffix to a CPT code, perform the following steps.

    1. Click Add to create a new row in the CPT to Revenue Code Mappings table.
    2. Click the CPT Code field and click the arrow to display a list of CPT codes. Then select a CPT code from the list.
    3. Click the Revenue Code Suffix field and enter a suffix number.
    4. Click Save to save your changes.

    The following are Medicare Part A Revenue Suffix Codes that may apply to your clinic.

    CPT Code Florida Only Non-Florida States
    97001 0 4
    97002 0 4
    97003 4 4
    97004 4 4
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