The following are detailed
instructions for completing the admission notice (CMS 1450 UB-04):
• Definition: Notify
the contractor responsible for processing your claims of the beneficiary’s
election of hospice benefits by forwarding Form CMS 1450 UB-04.
• Item
5. Federal Tax Number. Enter Tax Identification Number (TIN)
or Employer Identification Number (EIN) and the sub-identifier assigned
by the contractor.
• Item 8. Patient’s Name
Required. Show the patient’s name with the surname first, first
name, and middle initial, if any.
• Item
9. Patient’s Address Required. Show the patient’s full mailing
address including street name and number or RFD, city, state, and
zip code.
• Item 10. Patient’s Birthdate
Required. Show the month, day, and year of birth numerically
as MM-DD-YY. If the date of birth cannot be obtained after a reasonable
effort, leave this field blank.
• Item
11. Patient’s Sex Required. Show and “M” for male or an “F”
for female.
• Item 12. Admission Date
Required. Enter the admission date, which must be the same
date as the effective date of the hospice election or change of
election. The date of admission may not precede the physician’s
certification by more than two calendar days.
• Item
38. Transferring Hospice ID Required. Only when the admission
is for a patient who has changed an election from one hospice to
another.
• Item 58A, B, C. Insured’s
Name Required. If the primary payer(s) is other than TRICARE,
enter the name of person(s) carrying other insurance in 58A or 58A
and 58B as recorded on the ID card. If the TRICARE Program is primary,
enter the sponsor’s name as recorded on the ID card, in line 58A.
• Item
60A, B, C. Certificate/Social Security Number (SSN)/Health Insurance Claim/Identification
Number. If primary payer(s) is other than the TRICARE Program,
enter the unique ID number assigned by the primary payer to the person(s)
carrying other insurance in line 60A or 60A and 60B. Enter the sponsor’s SSN
in line 60B or 60C if the patient; or enter the DoD Benefits Number
(DBN) in line 60B or 60C if a North Atlantic Treaty Organization
(NATO)/Partnership for Peace (PfP) beneficiary.
• Item
67. Principle Diagnosis Code Required. For services provided
before the mandated date, as directed by Health and Human Services
(HHS), for International Classification of Diseases, 10th Revision
(ICD-10) implementation, show the full International Classification
of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis
code. For services provided on or after the mandated date, as directed
by HHS, for ICD-10 implementation, show the full ICD-10-CM diagnosis code.
The principal diagnosis is defined as the condition established
after study to be chiefly responsible for occasioning the patient’s
admission.
• Item 76. Attending Physician
ID Required. Enter the name, number and address of the licensed
physician normally expected to certify and recertify the medical necessity
of the services rendered and/or who has primary responsibility for
the patient’s medical care and treatment. Use Item 94 “Remarks”
for additional space for recording this information.
• Item
78. Other Physician ID Required. Enter the word “employee”
or “non-employee” here to describe the relationship that the patient’s
attending physician has with the hospice program.
• Items
85 and 86. Provider Representative Signature and Date Required. Deleted
from UB-04, see FL 45, line 23. A hospice representative makes sure
that the required physician’s certification and a signed hospice
election statement are in the records.