Medical professionals and healthcare facilities must complete different forms when billing for the services they provide. These are not forms you need to complete yourself.
Claim form CMS-1500 is for noninstitutional healthcare professionals, like primary care doctors. Form UB-04 (also known as form CMS-1450) is the standard claim form that institutional facilities use to bill healthcare claims for inpatient and outpatient healthcare services.
Facilities completing form UB-04 can add condition codes to indicate the circumstances relating to the bill that may affect its processing, such as codes attached to your outpatient treatment or hospital admission.
| Field | Description | Line |
|---|---|---|
| 01 | billing provider name, address, telephone number | 01 to 04 |
| 02 | billing providers’ payment details | 01 to 04 |
| 03a | patient control number (this number allows the facility to easily determine and retrieve your financial and clinical records) | – |
| 03b | medical/health record number | – |
| 04 | bill type | – |
Fields 18 through 28 of form UB-04 are specifically for condition codes.
Condition codes describe the healthcare services you may have received, the circumstances that may have led to you receiving those services, and anything else relevant to those services.
The National Uniform Billing Committee (NUBC) keeps lists of approved codes for form UB-04.
A Medicare Administrative Contractor (MAC) is a private health insurer that processes Original Medicare medical claims for those with Original Medicare. It also processes durable medical equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.
The Centers for Medicare & Medicaid Services (CMS) depends on its MAC network to act as the first point of operational contact between Medicare and the healthcare professionals and facilities enrolled in the program.
MACs are responsible for administering Original Medicare Part A and Part B claims as well as many other functions, including:
- processing Medicare claims
- making and accounting for Medicare payments
- enrolling healthcare professionals and facilities in the Medicare program
- handling reimbursements for services
- auditing institutional healthcare facility cost reports
- handling redetermination requests, which is the first stage of the Medicare appeals process
- responding to healthcare professional or facility inquiries
- educating healthcare professionals and facilities about Medicare’s billing conditions
- establishing local coverage determinations (LCDs)
- reviewing medical records relating to selected claims
- coordinating with CMS and other Medicare contractors
MACs that look after both Medicare Part A and Part B claims under Home Health & Hospice (HHH) Care and are also responsible for other business areas. These include receiving institutional claims and holding lists of the condition codes Medicare uses.
To meet auditing requirements, MACs must be able to capture all NUBC-approved data and pass all relevant information on to other claim payers with whom it has a coordination of benefits agreement.