What Claim Form Is Used for Hospital Services?

Healthcare billing and reimbursement rely on standardized claim forms for accurate communication between providers and payers. This documentation is important for hospital services, which encompass a wide range of inpatient and outpatient care. A unified billing approach is essential for efficient financial operations, ensuring clear, consistent information across numerous services, departments, and patient types. Without standardization, verifying services and securing payment would be significantly more challenging.

The Standard Claim Form for Hospital Services

The primary standardized claim form for billing hospital services in the United States is the UB-04, also known as the CMS-1450 form. This form is designed for institutional healthcare providers, including hospitals, skilled nursing facilities, rehabilitation centers, and home health agencies, to submit claims for reimbursement to various payers such as Medicare, Medicaid, and commercial insurance companies. The UB-04 serves as a comprehensive record of services provided, detailing charges associated with inpatient stays, outpatient surgeries, emergency room visits, diagnostic tests, and other facility-based care.

Institutional providers like hospitals utilize the UB-04 because it is tailored to capture the unique requirements of facility billing. For instance, the UB-04 accounts for charges related to room and board, medical equipment, and services from various hospital departments. The Centers for Medicare and Medicaid Services (CMS) developed and maintains this form in collaboration with the National Uniform Billing Committee (NUBC) to ensure consistency and accuracy in medical billing. Over 98% of Medicare claims and more than 80% of all institutional claims utilize the UB-04 form, highlighting its widespread adoption and importance in healthcare billing.

Essential Information on Hospital Claim Forms

The UB-04 form contains 81 specific fields, known as “Form Locators” (FL), each requiring precise information for proper claim processing and reimbursement. Accurate completion of these fields is important, as even minor errors can lead to claim denials or delays in payment.

Patient demographics are among the initial details required, including the patient’s full name, address, date of birth, and sex. This section also captures essential insurance information such as the policy number, group number, and specific insurance payer details. Ensuring that this information matches the patient’s insurance card precisely is important in preventing claim rejections.

Provider information is also important, encompassing the hospital’s name, address, and its National Provider Identifier (NPI). The NPI is a unique 10-digit identification number issued to healthcare providers in the United States, used to identify the entity submitting the claim. This attributes the claim to the rendering facility.

Service details include the dates of service, specifying the period covered by the bill, such as admission and discharge dates for inpatient stays. The “Type of Bill” (Box 4) is a four-digit code that identifies the facility type, type of care (e.g., inpatient, outpatient), and the frequency of submission (e.g., initial claim, replacement claim). This code provides important context for the services rendered.

Medical information is conveyed through standardized coding systems. Diagnosis codes, primarily from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), explain the patient’s condition or reason for treatment. Procedure codes, such as Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, describe the specific medical services and procedures performed. Additionally, revenue codes (FL 42) categorize the type of service or department that provided the care, such as room and board, pharmacy, or operating room services. These codes provide a detailed breakdown of the services for which the hospital seeks reimbursement.

Financial information on the UB-04 includes the total charges for services, broken down by revenue code, and any payment information received prior to submission. This section summarizes the financial aspect of the patient’s care. Accurate and complete entry of this information is essential for timely reimbursement and to avoid the financial repercussions of denied claims, which can result from incorrect coding or missing data.

How Hospital Claims are Submitted and Processed

Once a UB-04 form is accurately completed, it is submitted for review by the insurance payer. The vast majority of hospital claims are submitted electronically through Electronic Data Interchange (EDI), using the ANSI ASC X12N 837I format. This electronic method is highly efficient, reducing processing times and minimizing manual errors.

Paper claim submission is reserved for rare exceptions or when a provider qualifies for a waiver from electronic submission requirements. Electronic claims are routed through healthcare clearinghouses, which act as intermediaries between healthcare providers and insurance companies. Clearinghouses perform an important function by “scrubbing” claims for errors, inconsistencies, or missing information before forwarding them to payers. This pre-submission review helps reduce claim rejections and denials by ensuring claims meet the payer’s specific requirements and comply with industry standards.

Upon receiving a claim, the insurance company initiates a process called adjudication. During adjudication, the payer evaluates the claim against the patient’s policy benefits, medical necessity criteria, and coding accuracy. This review determines whether the services are covered, the amount to be reimbursed, and the patient’s financial responsibility. The outcome of adjudication can result in the claim being paid in full, paid at a reduced amount, or denied.

Following adjudication, the insurance company communicates its decision to both the healthcare provider and the patient. Providers receive an Electronic Remittance Advice (ERA), a digital version of the Explanation of Benefits (EOB). The ERA provides a detailed breakdown of the payment, any adjustments made, and reasons for denials, allowing the provider to reconcile their accounts. Patients receive an Explanation of Benefits (EOB), a statement explaining the services received, the amount covered by insurance, and any remaining balance they may owe.