All paper claims you submit must be on the appropriate CMS claim form.
The CMS claim form is available in red ink. This is the only format that is accepted. Photocopies are unprocessable.
NUBC (National Uniform Billing Committee) is responsible for the design of the form and award of the contract for printing of the CMS-1450 (UB-04) claim form. CMS does not supply the form to providers for claim submission.
You can obtain copies of the paper claim form from the Standard Register Company, Forms Division. The phone number should be found in your local yellow pages. Claim forms can also be obtained through office supply stores in your area.
Please remember that downloading a copy of the CMS-1450 (UB-04) paper claim form is not acceptable. The forms you obtain from either of the two resources noted above contain imbedded capabilities for OCR (Optical Character Recognition); in other words, the ability to scan your paper claim into the FISS (Fiscal Intermediary Shared System) claims processing system.
This information is located on the Electronic Billing & EDI Transactions page of the CMS website.
UB-04 Claim Sample
All institutional claims submitted on behalf of Medicare patients must be in the CMS-1450 (UB-04) claim format.
The CMS Claims Processing Manual, Pub 100-04, Chapter 25 contains general instructions for completing the CMS-1450 for Billing.
To learn more about to learn more about electronic filing requirements, including the EDI (Electronic Data Interchange) enrollment form that must be completed prior to submitting EMCs (Electronic Media Claims) or other EDI transactions to Medicare, please refer to the CMS Claims Processing Manual, Pub 100-04, Chapter 24.
Please visit the NUBC for data elements and codes included on the CMS-1450 and used in the 837I transaction standard.
CMS requires providers to submit their claims electronically. Please see the CMS Claims Processing Manual, Pub 100-04, Chapter 24, §90 concerning the mandatory requirement for electronic claims submission.
Novitas Solutions Electronic Billing department can assist you with questions concerning electronic claims submission. Please visit the EDI Center (JH) (JL) of our website.
Paper UB-04 claims must be submitted on the original claim format. Photo-copies are not permitted. Small providers (those with less than 25 full-time equivalent employees) are allowed to submit paper claims. Please see the CMS Claims Processing Manual, Pub 100-04, Chapter 24, §90 concerning the exception to the mandatory requirement for electronic claims submission.
CMS-1450 (UB-04) claims process through FISS. Claims are processed against system edits called reason codes. Each reason code is set to either RTP (return to provider), suspend, reject, deny, or pay. The reason code narrative explains why the claim received a particular edit.
There two methods you can use to review your claim status:
The ANSI ASC X12N 276/277 transaction is an electronic listing showing the status of your transmitted claims. If you currently do not receive this transaction, you will need to contact your vendor to discuss your system capabilities. Information regarding the 276/277 is found on the CMS website .
DDE is a method of claim submission, claim correction and claim status.
For more information on DDE, refer to the Electronic Billing page of our website (JH) (JL).
The Fiscal Intermediary Shared System Training Manual provides step-by-step instructions for claim inquiry.
Providers of service and (or) supplier must file with the Medicare contractor all claims for services and supplies provided to Medicare beneficiaries. Effective January 1, 2010, claims must be submitted within one year of the date of service. For example, services rendered on October 1, 2014 must be submitted by October 1, 2015.
For more details, please refer to the CMS Claims Processing Manual, Pub 100-4, Chapter 1, §70.
Note: The 12-month timely filing period is the date of service or ‘From’ date on the claim. Medicare uses the line item ‘Through’ date to determine the filing timeliness for claims that include span dates of service (a ‘from’ and ‘through’ date span on the claim).