UB-04 Highlights: Sample Claim
See UB-04 Highlights: Sample Claim for Hospice Care [PDF] for a sample of the claim explained below.
Explanation of sample claim
| Form Indicator | Form Locator | Explanation |
|---|---|---|
| ❶ | 4 | Type of bill 811 indicates the type of facility is a special facility (8), the bill classification is a non-hospital-based hospice (1) and the frequency is admit through discharge (1). |
| ❷ | 6 | Beginning and ending service dates of the period included on the bill correspond to the number of days covered. |
| ❸ | 15 | The number 5 indicates that the patient was transferred from a skilled nursing facility (SNF) level of care. |
| ❹ | 42 | The correct revenue codes are used to bill for the level of hospice care provided. |
| ❺ | 45 | Service dates are consistent with those listed in form locator 6. |
| ❻ | 67 | All services on the claim must be appropriate for the principal diagnosis code listed in form locator 67. |
Notes:
- Form Locator 42: Because residential care is recognized by HMSA but is not a service covered under Medicare, please ensure that the charges for residential care (revenue code 659) are billed separately from routine home care (revenue code 651) when Medicare is the primary insurer. The charges can appear on the same claim but must be listed separately.
- Form Locator 67: For more information on the principal diagnosis code, refer to Diagnosis Coding for Principal Diagnosis
Billing Tips
First-time claim
When billing the first claim for an HMSA member receiving hospice care, please attach the following to the UB-04 claim:
- A physician certification indicating that the beneficiary is terminally ill and has a life expectancy of six months or less
- A member agreement (signed by the member) demonstrating that the member has elected to receive hospice benefits and understands the consequences of discontinuing hospice care and resuming Basic Benefits
Note: Members may discontinue hospice care and receive treatment for the terminal illness at any time. If members wish to re-enroll into the hospice benefit, they can do so at any time (but will again waive the right to receive treatment for the terminal illness).
Subsequent hospice claims for revenue code 0659 do not need certification and a member agreement. This is only needed for the first claim. Subsequent claims can be submitted electronically.
Medicare patients
For Medicare Advantage Plans, refer to Medicare Advantage Hospice VBID.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |