UB04 Step by Step - Billing using the UB04 (2024)

This topic covers the pieces of the "puzzle" of the UB04 that to complete for claim submission. Your job is to determine the requirements for your payor, and place items in the appropriate fields of Generations. Use the line-by-line breakdown to help determine correct placement. The steps are:

• Company Settings
• Service Codes
• Payor Master List
• Physician Master List
• Client Personal Data
• Client UB04
• Service Order (Optional)
• Schedules and Timesheets
• Create the UB04 or 837i

Videos

Watch an overview of the UB04.

Learn about notable fields in the UB04.

Watch a video about generating a UB04.

Company Settings

In Admin > Company Settings > Company Information, add company name, tax ID, address, city, state, zip.

Service Codes

Add Revenue Code, Description, CPT/HCPCS Codes, and Cost for appropriate items in the Service Code Master List. The information placed here depends on the requirements of your payor.

Payor Master List

Complete the Payor ID field.

To use the 837i for electronic billing, also complete the Payor EDI information. Contact your payor or clearinghouse regarding the correct information to put into these fields. Below is an example where Availity is the clearinghouse.

Physician Master List

The following fields from the Physician area are used on the UB04:

• First Name
• Last Name
• Taxonomy Code (2 characters)
• Taxonomy Number (10 characters)
• Physician Qualifier ID and number

Client Personal Data

The following fields from the Client Personal Data screen are used on the UB04:

• Client ID. This is the number in parentheses under the photo.
• Client name, address, birth date, gender
• Referral #
• Service Start Date
• Medical Record Number
• Payor
• Diagnosis Code
• Physician

Client UB04

Browse to the client and down to the bottom of the Personal Data page. Add a checkmark to Enable UB04, and click the blue UB04 button.

A UB04 specifically for this person opens. Complete information as required by your payor. Note that all of the lines are numbered; use the numbers when looking at the Line-By-Line breakdown.

Notable Lines

Line 4

Type of Bill. 4 digits alphanumerical number providing 3 pieces of information after a leading zero. Example: 0333

• 0 = Leading 0
• 3 = Home Health
• 3 = Outpatient/HHA
• 3 = Interim Continuing Claims

Line 8a

Patient ID. You can also use the patient number from a Service Order.

Line 15

SRC also known as source of referral.

Line 17

STAT also known as patient discharge status.

Line 52a

Release of Information.

• Select one from the dropdown.
• Y=yes
• I=Informed Consent

Line 53a

Assign Benefits.

• Select one from the dropdown.
• Y=yes
• N=no
• W=waiting

Line 66 Primary Diagnosis

You can also use the diagnosis from the Client Personal Data tab.

Line 66 Other Diagnosis

• (Optional)
• Click the magnifying glass to search for a diagnosis code or manually type the code.

See the Line By Line breakdown for information about other fields.

Service Order

Also known as authorizations, Service Orders track the number of hours or dollars allowed by a third party payor - typically Medicaid, the Veteran's Administration, or an insurance company. They are optional. When scheduling with a service order, Generations alerts you if you create schedules that would exceed the established limitations.

• Patient # can be used for Lines 8a and 60.
• Authorization # can be used for Lines 51 and 63.
• Include service modifiers when billing using 837
  • Only used for the electronic version of the UB04.
  • You may find that one Payor requires a Service Code modifier, while another does not.
  • Adding a checkmark here includes modifiers for this specific client.

Schedule and Timesheets

Schedule and work with Timesheets as normal. If you're using Service Orders, be sure that you select a Service Order for every schedule.

Create the UB04 or 837i

The UB04 and 837i are generated from Reports > Billing > Billing Report by Client > UB04 parameters. We strongly recommend reviewing the form before sending to a clearing house or printing for submission.

Report Format

• Printed: Creates a PDF for you to print and submit to a the payor.

• Pre-printed: Creates a document you can use to print on the pre-printed forms.
• Print Image: Creates a .TXT file for you to submit to a clearinghouse. Print image files are being phased out as they are being replaced with the 837 format.

• 837i : Creates a .TXT file for you to submit to a clearinghouse. Read more below.

• Prod/Test menu (only shows when 837i is selected.) Select one.
  • Production is an actual claim that you want to send to the clearinghouse for consideration; it places a P in the ISA15 segment of the 837i.
  • Test is for creating a test file; it places a T in the ISA15 segment of the 837i.
• Original/Reissue menu (only shows when 837i is selected.) Select one.
  • Original: Used for the initial submission of a claim for this individual.
  • Reissue: Used when reissuing claims.

Other Options

• Include Other Expenses: If checked, includes Other Expenses on the UB04.
• Populate line 60 with Medical Record #:Add a checkmark to place the Medical Record # from Client Personal Data into Line 60.
• Summarize Daily by Service: If checked, summarize per service per day. Only applies if the same service is performed more than one time per day.
• Mark Timesheets as billed when running UB04:If checked, marks Timesheets associated with the UB04 as billed.
• Enable Interchange Acknowledgement Request (TA1): This is ISA14 and the default is unchecked and the value is 0. When checked, a 1 is placed in the field.
• Billing Provider NPI: This field is required and completes line 56. Enter your NPI, name, address, city, state, and zip code here.
• Page Totals: Select one: total on last page only or running totals on each page.

The Pre-Printed Form

When using the pre-printed form, there are two recommended methods of getting the form to line up correctly. Both require a checkmark in both "UB04" and "Pre-printed form" plus some trial and error on your behalf.

Adjust Margin Offset

At the bottom of the UB04 parameters in the Billing Report By Client, you can offset the Top and Left margins.

• Start with the Top Offset at -0.14 and Left Offset at -3.
• Test on a pre-printed form, then adjust the offset as needed.
• Generally, you should only need small adjustments. For example, if the form needs to move down slightly, change the Top Offset slightly and try printing again.
• Generations remembers the Offset settings for the next time you run the UB04.

Adjust Page Scaling

When printing the UB04 using the pre-printed forms to Adobe Acrobat, you may be able to change the Page Scaling in Adobe Acrobat to "None." The ability to adjust Page Scaling is different depending on the version of Adobe Acrobat your office utilizes.

1. Run the report
2. In Adobe Reader select File > Print
3. Select "Actual Size" and "Portrait" orientation.

837i Electronic Claims

When you click OK, Generations automatically validates the required fields. A new tab opens and you see two links:

Click and download the validation report (if any.)

• If you do have a validation report, there are items that must be corrected.
• Use the line-by-line to help figure out where things need to be changed and repeat this process until there are no validation errors.

Once your validations are cleared, download the Claim Report and save. Then you can upload to your clearinghouse using their instructions.

ANSI Format

If your clearinghouse asks for the file in ANSI format, you can do that. Save the file and then:

• Open the .txt from Generations
• File > Save as
• In the encoding box, select ANSI
• Save the file and upload to your clearinghouse.

Reading and Understanding the 837i

There are three types of 837s: the 837D for dental practices, the 837p for professionals, and the 837i for institutions. The 837 files are separated into loops, segments, and elements that contain specific information. Here's a claim for client Trevor Nartker; the claim is for T1019 service on December 4, 2023.

• Loops are broken into five primary sections: billing provider, subscriber, client, claim information, and service line information. Loops generally begin with an HL or NM1.
• Asterisks (*) separate elements. Several asterisks in a row mean that the element is empty.
• Colons (:) separate sub-elements. Several colons in a row mean the sub-element is empty.
• Tildes (~) end lines and separate segments. Separating a file out this way can help with troubleshooting. Here is part of the claim broken out by line.

The things at the top of the claim are known as the header. Much of this comes from the Payor area of Generations.

This is the billing provider information.

The subscriber/client information is next.

Followed by the payor.

CLM signifies the start of the claim.

• DTP is statement dates.
• CL1 is institutional claim codes.
• HI*ABK is the principal diagnosis

Next is the attending provider/physician information.

And then more claim information.

• LX*1 is a service line counter
• SV2 indicates institutional service (and there's the T1019 and the 60.)
• DTP is date of service.

Let's look at the client name information closer.

• HL*2*1*22*0~ is the start of the 2000B Subscriber HL Loop
• SBR*P*18*******MC~ is the SBR subscriber information.
• NM1*IL*1*Nartker*Trevor****MI*123456789 is the 2010CA Loop for patient name.
• N3*7338 North Alger Road~ is the patient address.
• N4*Alma*MI*48801~ is the city, state, and zip code of the patient.
• DMG*8*19400515*M~ is patient demographic information.

That's the basics on reading an 837i file. There is a lot more to learn, and a good place to start is on the X12 website or by searching "how to understand an 837i."