Index

• Sections
  • UB-04 Guide
  • I.  Settings & Directories
  • A.  Group Level Settings
  • 1. Sites/Letterheads
  • B. Specific to Individual Level Settings
  • 2. Billing Rates & Payer Rules
  • II.  Patient Demographics
  • A. Patient Info
  • B. Insurance Info
  • III.  Patient Accounts
  • IV.  UB04 Form in ICANotes
  • A. Organizational Details (Box 1-6)

UB-04 Guide

I.  Settings & Directories

A.  Group Level Settings

1. Sites/Letterheads

• Create New Facility if needed.
• Make sure to use 9-digit zip code.
• Push information to Letterhead tab.
• Push information to Electronic Billing tab.
• NOTE: Service Facility Address displays in Box 1 and 2 of UB04.
• No Save button is necessary for this section.

     2. Service/Mod Codes

• Select CPT/HCPCS code for appropriate setting.
• Enter in Revenue codes and appropriate daily rates.
• Link the Revenue codes to the corresponding CPT/HCPCS code.
• Enter the modifiers your facility uses in Modifier Code Short List, if applicable.

     3. Insurance Payers 

• Click to add a new insurance.
• Enter in at least the details highlighted in yellow.
• Make sure you have the Institutional Payer IDs for UB04, not the Professional Payer IDs for CMS 1500/HCFA forms.
• Click .
• If you need edit any existing insurance, click on the payer name in the left column, edit it and then click on .
• Changes will update for all patients who have previously been assigned to that payer via the Short List of Insurance Payers.

B. Specific to Individual Level Settings

     1. Personal Info

• To be completed for each individual provider.
• Fill in at least the yellow required fields.
• To go to next provider, click on their name in the left column. If you do not see a list of names, then you do not have access and need to refer to your Administrator.
• No Save button is necessary for this section.

2. Billing Rates & Payer Rules

• To be completed for each individual provider.
• Click on the Short List option and use drop-down arrows to select codes from the previously created Short List in the Service Codes/Mod tab.
• If applicable, select modifiers next to codes.
• Enter in the corresponding billing rates, i.e. 100 for $100.00.

• Enter Provider Payer Rules if applicable, i.e. Billing under Supervisor or taxonomy code for specific insurance payers.
• No Save button is necessary for this section.

II.  Patient Demographics

A. Patient Info

Ensure the required billing fields are entered in addition to the following:

• Date of Current Admission: From XXXXX

• Date of Discharge (if applicable): To XXXXX
• Release of Information: Y or N

B. Insurance Info

Ensure the required billing fields are entered in addition to the following with the UB04 Payer ID:

Assignment of Benefits:  Yes or No

III.  Patient Accounts

1. Access the UB-04 tab for the patient.
2. Click  button to create new UB04 form.
3. Select the stay you want to bill and click , or simply click  to skip this step.  (These dates are pulled from the Demographics.)

4. To edit current UB04, click the Edit pencil next to the one you want to edit.

IV.  UB04 Form in ICANotes

A. Organizational Details (Box 1-6)

1. Provider Name: Settings & Directories, Group Level, Sites/Letterheads
2. Beneficiary Name: Settings & Directories, Group Level, Sites/Letterheads
3. Patient Control # and Medical Record #: Demographics, Patient Info
4. Type of Bill, i.e. 131 for IOP
5. FED Tax #: Settings & Directories, Specific to Individual, Personal Info
6. Statement Covers Period From XX/XX/XXXX To XX/XX/XXXX.

   B. Patient (Box 8-41)

    8. Patient Name and Patient ID

    9. Patient Address, City, State and Zip

    10. DOB = Date of Birth

    11. Sex = M,