What is hospital (UB 04) institutiona claim?

What is insurance claim ?

According to Medicare it has to be fulfill the below three points.


1. it must be filed with the appropriate Medicare contractor,
2. it must be filed on the prescribed form and
3. it must be filed in accordance with all pertinent CMS instructions.

The sections below define each of these conditions in greater detail.


Appropriate Medicare Contractor


Submissions for services provided by institutions must be filed with a Medicare Fiscal Intermediary. It is the provider’s responsibility to submit each claim to the appropriate contractor. Medicare contractors may attempt to re-route claims appropriately if they have enough information to do so. In the case of re-routed claims, services submitted for payment for institutional services to Medicare carriers are not considered claims under Medicare regulations until received by the appropriate FI.


Form Prescribed by CMS


Regulations at 42 CFR 424.32 (b) prescribe the claim forms that must be used in terms of paper forms. The paper form prescribed for institutional providers is Form CMS-1450, also known as the UB-04 uniform billing form. However, the Administrative Simplification Compliance Act mandated the electronic submission of all Medicare claims received on or after October 16, 2003, with a very limited number of exceptions as defined in regulations. Even prior to this mandate, the overwhelming majority of Medicare claims were submitted in electronic formats, so the electronic format equivalent to the paper form is key to determining the prescribed form used in a submission.

The prescribed electronic format for Medicare institutional claims was defined by HIPAA as the 837 institutional claim transaction as defined by the American National Standards Institute Accredited Standards Committee X12. Services submitted for payment by institutional providers on a format other than the 837 I, or its paper equivalent in the limited case where applicable, are not considered claims under Medicare regulation. Claims submitted on paper forms are entered into Medicare’s electronic claims processing system and converted into electronic records in order to be processed. After the point of entry into the electronic system, handling of claims submitted on the prescribed electronic format and on its paper equivalent is identical with regard to determining timely filing


In Accordance with CMS Instructions


The CMS instructions for submitting institutional claims to Medicare are contained in this manual. General instructions that reflect guidance on the use of the paper UB-04, as established by the National Uniform Billing Committee. These instructions apply to all institutional claim types. Additional chapters in this manual supplement these general instructions. For example, see instructions for inpatient hospital billing in Chapter 3, or inpatient skilled nursing billing in Chapter 6. In order to constitute a Medicare claim, services submitted for payment must be entered in a claim format in accordance with these instructions. Services submitted for payment in a manner not complete and consistent according to these instructions will not be accepted into Medicare’s electronic claims processing system and will not be considered filed for purposes of determining timely filing

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