Troubleshooting Potential UB-04 Issues

Although TRICARE Management Activity (TMA) recently announced that it extended the dual use period for the CMS-1500 (12-90) and CMS-1500 (08-05) form as well as the CMS-1450 (UB-92) and the CMS-1450 (UB-04) form until December 31, 2007, hospitals and other institutional providers are still encouraged to obtain the new UB-04 form and file their claims electronically.

The new UB-04 data set accommodates the National Provider Identifier (NPI) and incorporates a number of other important changes and improvements. One of these changes is the fact that the new UB-04 form doesn’t require a signature by the provider.

We have discovered that a few claims clearinghouses have been incorrectly dropping an electronically-submitted UB-04 into the UB-92 paper claim format (which has a signature requirement), not putting a signature on the claim, and then submitting the paper claim to Wisconsin Physicians Service (WPS). While an electronically-submitted UB-04 doesn’t need a signature, the proper claims process requires WPS to return the incorrectly submitted UB-92 paper claim to the provider because it lacks a signature. While we believe this is not a major problem, here are some steps that affected providers can take if this occurs.

Identifying How the Returned Claim was Submitted to WPS

When a claim is returned, a copy of the claim is attached to the cover letter. The letter will reference a claim number. The format for the 14-digit claim number is:

• The first four digits = the year claim was received
• Next three digits = the Julian date claim was received (Each day of the year has a number 1-365; e.g., February 1 = 032)
• The next seven digits are the sequence:
  • If the first digit of the sequence is a 0, zero, it denotes a paper claim
  • If the first digit of the sequence is a 3, it denotes a paper claim scanned through Optical Character Recognition (OCR)
  • If the fist digit of the sequence is a 4, it denotes a claim submitted online at www.triwest.com
  • If the first digit of the sequence is a 9, it denotes an electronically submitted claim

Here are some claim number examples:

• Claim 2007121-0XXXXXX indicates the claim was received on paper on May 1, 2007.
• Claim 2007121-3XXXXXX indicates the claim was received on paper on May 1, 2007 and scanned into the system using OCR.
• Claim 2007121-9XXXXXX indicates the claim was received electronically on May 1, 2007.

Is the claim in a UB-92 format or a UB-04 format?

When WPS returns a claim to you, a copy of the form that was submitted will be included. By checking this form, you can determine if it was a UB-92 form or a UB-04 form. Remember that a UB-92 requires a signature while a UB-04 does not. If you’re submitting electronically through a clearinghouse and the claim has a sequence starting with a 0 or 3, you should contact your clearinghouse and ask:

• Why was the claim dropped to paper?
• Why was it dropped to a UB-92 format?

If you believe an electronically submitted UB-04 claim was incorrectly returned for signature, you should call 1-888-TRIWEST (874-9378) for resolution. You should have any examples of the UB-04 claims returned for signature available when making the call.

Further information on the UB-92 and the UB-04, an instruction manual for subscribers, and the forms for purchase are available at http://www.nubc.org/. There also is a CMS fact sheet about the UB-04 form.