Instructions for Form CMS-1450 "Institutional Billing Form (Hospitals)" - Florida

This document contains official instructions for Form CMS-1450, Institutional Billing Form (Hospitals) - a form released and collected by the Florida Department of Financial Services.

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Download Instructions for Form CMS-1450 "Institutional Billing Form (Hospitals)" - Florida

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DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
FORM DFS-F5-DWC-90-A (UB-04) COMPLETION INSTRUCTIONS
FOR HOSPITALS
HOSPITALS SHALL COMPLETE THE DFS-F5-DWC-90 (UB-04) ACCORDING TO THESE INSTRUCTIONS AND THE
NATIONAL UNIFORM BILLING COMMITTEE OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL (UB-04 MANUAL),
AS INCORPORATED BY REFERENCE IN RULE 69L-8.073, F.A.C., AND THE PROCEDURE SPECIFICATIONS SHOWN
BELOW.
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
PROVIDER NAME,
NO
1
REQUIRED
Enter the provider's name and a valid telephone
ADDRESS AND
number and the physical address (including zip
TELEPHONE
code) of the place where services were rendered.
NUMBER
PAY-TO NAME
NO
2
REQUIRED
Enter the name and address where the provider
AND ADDRESS
listed in Field Number 1 expects payment to be
remitted.
PATIENT
3a
CONDITIONAL
CONTROL
NO
NUMBER
MEDICAL/HEALTH
NO
3b
CONDITIONAL
Pursuant to the UB-04 Manual.
RECORD NUMBER
TYPE OF BILL
YES
4
REQUIRED
Pursuant to the UB-04 Manual.
FEDERAL TAX
YES
5
REQUIRED
Enter the Federal Tax Identification Number of
NUMBER
the Hospital where the service is provided. Also
known as the Tax ID number (TIN).
DFS-F5-DWC-90-A
COMPLETION INSTRUCTIONS FOR HOSPITALS
Rule 69L-7.720, F.A.C.
Revised 12/08/2015
Page 1 of 12
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
FORM DFS-F5-DWC-90-A (UB-04) COMPLETION INSTRUCTIONS
FOR HOSPITALS
HOSPITALS SHALL COMPLETE THE DFS-F5-DWC-90 (UB-04) ACCORDING TO THESE INSTRUCTIONS AND THE
NATIONAL UNIFORM BILLING COMMITTEE OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL (UB-04 MANUAL),
AS INCORPORATED BY REFERENCE IN RULE 69L-8.073, F.A.C., AND THE PROCEDURE SPECIFICATIONS SHOWN
BELOW.
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
PROVIDER NAME,
NO
1
REQUIRED
Enter the provider's name and a valid telephone
ADDRESS AND
number and the physical address (including zip
TELEPHONE
code) of the place where services were rendered.
NUMBER
PAY-TO NAME
NO
2
REQUIRED
Enter the name and address where the provider
AND ADDRESS
listed in Field Number 1 expects payment to be
remitted.
PATIENT
3a
CONDITIONAL
CONTROL
NO
NUMBER
MEDICAL/HEALTH
NO
3b
CONDITIONAL
Pursuant to the UB-04 Manual.
RECORD NUMBER
TYPE OF BILL
YES
4
REQUIRED
Pursuant to the UB-04 Manual.
FEDERAL TAX
YES
5
REQUIRED
Enter the Federal Tax Identification Number of
NUMBER
the Hospital where the service is provided. Also
known as the Tax ID number (TIN).
DFS-F5-DWC-90-A
COMPLETION INSTRUCTIONS FOR HOSPITALS
Rule 69L-7.720, F.A.C.
Revised 12/08/2015
Page 1 of 12
FORM DFS-F5-DWC-90-A (UB-04) COMPLETION INSTRUCTIONS
FOR HOSPITALS
HOSPITALS SHALL COMPLETE THE DFS-F5-DWC-90 (UB-04) ACCORDING TO THESE INSTRUCTIONS AND THE
NATIONAL UNIFORM BILLING COMMITTEE OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL (UB-04 MANUAL),
AS INCORPORATED BY REFERENCE IN RULE 69L-8.073, F.A.C., AND THE PROCEDURE SPECIFICATIONS SHOWN
BELOW.
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
STATEMENT
YES
6
REQUIRED
Enter dates of service in MMDDYY format.
COVERS PERIOD
RESERVED (FOR
NO
7
NOT REQUIRED
USE BY THE
NUBC)
PATIENT
NO
Enter the patient’s name: last, first, and middle
8a
REQUIRED
NAME/IDENTIFIER
initial if applicable.
PATIENT
YES
Enter the patient’s Social Security Number or
8b
REQUIRED
NAME/IDENTIFIER
Division Assigned Number.
PATIENT ADDRESS REQUIRED
NO
Enter the patient’s mailing address, including
9 a-e
street address, apartment number or other
identifier, city, state, and zip code.
Enter the patient’s date of birth in
10
PATIENT
NO
REQUIRED
BIRTHDATE
MMDDYYYY format.
11
PATIENT SEX
Enter the sex of the patient: M=Male,
NO
REQUIRED
F=Female
U=Unknown
12
ADMISSION DATE
Required for inpatient services pursuant to the
YES
CONDITIONAL
UB-04 Manual.
DFS-F5-DWC-90-A
COMPLETION INSTRUCTIONS FOR HOSPITALS
Rule 69L-7.720, F.A.C.
Revised 12/8/2015
Page 2 of 12
FORM DFS-F5-DWC-90-A (UB-04) COMPLETION INSTRUCTIONS
FOR HOSPITALS
HOSPITALS SHALL COMPLETE THE DFS-F5-DWC-90 (UB-04) ACCORDING TO THESE INSTRUCTIONS AND THE
NATIONAL UNIFORM BILLING COMMITTEE OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL (UB-04 MANUAL),
AS INCORPORATED BY REFERENCE IN RULE 69L-8.073, F.A.C., AND THE PROCEDURE SPECIFICATIONS SHOWN
BELOW.
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
13
ADMISSION HOUR CONDITIONAL
Required for all inpatient claims pursuant to the
YES
UB-04 Manual
Required for scheduled outpatient surgery and
related labs and clinical services.
14
ADMISSION TYPE
REQUIRED
Pursuant to the UB-04 Manual
NO
15
ADMISSION
NOT REQUIRED
NO
SOURCE
16
DISCHARGE HOUR CONDITIONAL
Required for all final bills pursuant to the UB-04
NO
Manual.
17
PATIENT
REQUIRED
Pursuant to the UB-04 Manual
NO
DISCHARGE
STATUS
Enter code “02” in Form Locator 18.
18
CONDITION
REQUIRED
NO
CODES
19-28
CONDITION
Use of other applicable codes from the UB-04
CONDITIONAL
NO
CODES
Manual is optional (if other codes are listed, list
them in alphanumeric order in Form locators 19
through 28).
29
ACCIDENT STATE
NOT REQUIRED
NO
DFS-F5-DWC-90-A
COMPLETION INSTRUCTIONS FOR HOSPITALS
Rule 69L-7.720, F.A.C.
Revised 12/8/2015
Page 3 of 12
FORM DFS-F5-DWC-90-A (UB-04) COMPLETION INSTRUCTIONS
FOR HOSPITALS
HOSPITALS SHALL COMPLETE THE DFS-F5-DWC-90 (UB-04) ACCORDING TO THESE INSTRUCTIONS AND THE
NATIONAL UNIFORM BILLING COMMITTEE OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL (UB-04 MANUAL),
AS INCORPORATED BY REFERENCE IN RULE 69L-8.073, F.A.C., AND THE PROCEDURE SPECIFICATIONS SHOWN
BELOW.
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
30
RESERVED (FOR
NOT REQUIRED
NO
USE BY THE
NUBC)
Enter code “04” and enter the date of the
31
OCCURRENCE
REQUIRED
NO
CODES AND
accident/illness/injury as MMDDYY
DATES
32-34
OCCURRENCE
CONDITIONAL
Pursuant to the UB-04 Manual
CODES AND
NO
DATES
35-36
OCCURRENCE
NOT REQUIRED
SPAN CODES AND
NO
DATES
37
RESERVED (FOR
NOT REQUIRED
NO
USE BY THE
NUBC)
38
RESPONSIBLE
REQUIRED
Enter the name and mailing address of the
NO
workers’ compensation insurer/claim
PARTY NAME AND
ADDRESS
administrator identified in Field Number 50.
Must enter name, address and zip code.
39-41
VALUE CODES
NOT REQUIRED
NO
AND AMOUNTS
42
REVENUE CODE
REQUIRED
Enter a four digit Revenue Code beside each
YES
service described in column 43. The first digit is
a leading zero. See NUBC Manual for specific
codes. After the last Revenue Code, enter
“0001” corresponding with the Total Charges
amount in Column 47.
DFS-F5-DWC-90-A
COMPLETION INSTRUCTIONS FOR HOSPITALS
Rule 69L-7.720, F.A.C.
Revised 12/8/2015
Page 4 of 12
FORM DFS-F5-DWC-90-A (UB-04) COMPLETION INSTRUCTIONS
FOR HOSPITALS
HOSPITALS SHALL COMPLETE THE DFS-F5-DWC-90 (UB-04) ACCORDING TO THESE INSTRUCTIONS AND THE
NATIONAL UNIFORM BILLING COMMITTEE OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL (UB-04 MANUAL),
AS INCORPORATED BY REFERENCE IN RULE 69L-8.073, F.A.C., AND THE PROCEDURE SPECIFICATIONS SHOWN
BELOW.
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
43
REVENUE
REQUIRED
Enter a brief description that corresponds to the
NO
DESCRIPTION
Revenue Code in column 42.
44
HCPCS/RATES/
CONDITIONAL
Pursuant to the UB-04 Manual.
NO
HIPPS RATE
CPT, HCPCS, or workers compensation unique
CODES
code(s) and modifier(s) required for all
applicable REV codes.
45
SERVICE DATE
CONDITIONAL
Required on outpatient bills, pursuant to the UB-
YES
04 Manual.
Service Date: Enter the date services are
provided. (Applies to Lines 1-22 only.) Use
MMDDYY format.
Creation Date: Enter the date in MMDDYY
format that the bill is created on Line 23. This
date shall be reported on all pages of the bill.
46
SERVICE UNITS
REQUIRED
Pursuant to the UB-04 Manual.
NO
47
TOTAL CHARGES
REQUIRED
Enter total charges related to the revenue code
NO
for the current billing period noted in Field #6.
Total charges for both covered and non-covered
services.
48
NON-COVERED
NOT REQUIRED
NO
CHARGES
49
RESERVED (FOR
NOT REQUIRED
NO
USE BY THE
NUBC)
DFS-F5-DWC-90-A
COMPLETION INSTRUCTIONS FOR HOSPITALS
Rule 69L-7.720, F.A.C.
Revised 12/8/2015
Page 5 of 12
Page of 12