Residential Care Home
Billing Guide for the UB-04

Commonwealth of Massachusetts
Executive Office of Health and Human Services
December 2011

BG-UB-04-RCH (Rev. 12/11)

Table of Contents  
Introduction							1
General Instructions for Submitting Paper Claims		1
Entering Information on the UB-04 Claim Form			1
Time Limitations on the Submission of Claims			1
General Instructions for Submitting Paper Claims (cont.)	2
Electronic Claims						2
Where to Send Paper Claim Forms					2
Further Assistance						2
How to Complete the UB-04 Claim Form				3


Introduction
Residential care homes choosing to submit their claims on paper must use the UB-04 claim form to 
submit their claims. This document provides detailed instructions for completing the paper UB-04 
claim form.

Residential care home services are not covered by MassHealth. However, the Commonwealth of 
Massachusetts uses the MassHealth claims payment system to process claims on behalf of the 
Department of Transitional Assistance (DTA) for payment of residential care home services provided 
to residents receiving DTA assistance. For administrative purposes, MassHealth issues a 10-character 
identification number/service location code that permits residential care homes to submit claims 
through the MassHealth claims payment system.

For information about submitting claims electronically, see the 837I Companion Guide for Residential 
Care Homes.

For information about the resulting remittance advice, see the MassHealth Residential Care Home 
Guide to the Remittance Advice for Paper Claims and Equivalents at www.mass.gov/masshealth. Go 
to MassHealth Regulations and Other Publications. Click on Provider Library and then on MassHealth 
Billing Guides for Paper Claim Submitters.

Please Note: Effective January 1, 2012, MassHealth is moving toward an all-electronic claims 
submission policy to achieve greater efficiency. All claims must be submitted electronically, unless the 
provider has received an approved electronic claim submission waiver. 90-day waiver requests and 
final deadline appeals may be submitted either electronically via the Provider Online Service Center 
(POSC) or on paper. 
Please see All Provider Bulletin 217, dated September 2011, for more information about MassHealth’s 
paper claims waiver policy. For information on how to submit 90-day waiver requests and final 
deadline appeals electronically, please also see All Provider Bulletin 220 and All Provider Bulletin 
221, dated December 2011.
General Instructions for Submitting Paper Claims

Entering Information on the UB-04 Claim Form 

*	Complete a separate claim form for each resident receiving DTA assistance.
*	Type or print all applicable information (as stated in the instructions) on the claim form, using 
black ink only. Be sure all entries are complete, accurate, and legible.
*	For each claim line, enter all required information as applicable, repeating if necessary. Do not use 
ditto marks or words such as “same as above.”
*	When a required entry is a date, enter the date in MMDDYY or MMDDYYYY format.

Time Limitations on the Submission of Claims

Claims must be received within 90 days from the through date entered in Field 6 (Statement Covers 
Period) of the UB-04 claim form.



General Instructions for Submitting Paper Claims (cont.)

Electronic Claims

To submit electronic claims, refer to the 837I Companion Guide for Residential Care Homes or contact 
the Electronic Data Interchange (EDI) Department at 1-800-841-2900, Option 1, Option 8, then 
Option 3.  

Please Note: When submitting electronic files to MassHealth, be sure to review this UB-04 billing 
guide, the 837I Companion Guide, and our Billing Tips flyers to determine the appropriate 
requirements for submitting electronic files to MassHealth. These documents can be found on the 
MassHealth web site at www.mass.gov/masshealth.

Where to Send Paper Claim Forms

Paper claims should be submitted to the following address.

MassHealth
P.O. Box 9118
Hingham, MA 02043

Keep a copy of the submitted claim for your records. Please note that MassHealth does not accept mail 
with postage due.

Further Assistance

If, after reviewing the following field-by-field instructions, you need additional assistance to complete 
the UB-04 claim form, please contact MassHealth Customer Service at 1-800-841-2900.


How to Complete the UB-04 Claim Form 
A sample of the front of the UB-04 claim form is shown below. A sample of the back of the form is on 
the next page. Following this sample are instructions for completing each field on the UB-04 claim 
form. Refer to the National Uniform Claim Committee (NUBC) instruction manual available at 
www.nubc.org.
 


 



Field No.
Field Name
Description
1
(Unnamed)
Enter the residential care home’s name, doing business as 
(DBA) address, city, state, zip code, and telephone 
number.
Please Note: The Billing Provider Address must be a street 
address. Do not use P.O. boxes or lock boxes.
2
(Unnamed)
Not required
3a
Pat Cntl #
Enter the resident control number, if it is assigned by the 
residential care home. If one is not assigned, enter the 
resident’s last name.
3b
Med. Rec. #
Not required
4
Type of Bill
Residential care homes should use type of bill (TOB) 021x. 
Please refer to the list below.
0210   Nonpayment/Zero
0211   Admit through Discharge Claim
0212   Interim-First Claim
0213   Interim-Continuing Claim
0214   Interim-Last Claim
0215   Late Charges Only
0217   Replacement
0218   Void
5
Fed. Tax No.
Enter the residential care home’s federal tax ID number.
6
Statement Covers 
Period 
From/Through
Enter the beginning and ending dates of the period 
included on this bill in MMDDYYYY format. Do not bill 
for more than one calendar month on a claim.
7
(Unnamed)
Not used
8a
Patient Name
Not required
8b
Patient Name
Enter the name of the resident in the following order: last 
name, first name, middle initial.
9a
Patient Address
Enter the street address of the residential care home.
9b
Patient Address
Enter the city of the residential care home.
9c
Patient Address
Enter the state of the residential care home.
9d
Patient Address
Enter the zip code of the residential care home.
9e
Patient Address
Not required
10
Birthdate
Enter the resident’s date of birth in MMDDYYYY format.
11
Sex
Enter an “M” or “F” to indicate the resident’s gender.
12
Admission Date
Enter the date of the resident’s initial admission to the 
residential care home or the date of the most recent 
readmission following a three-day hospital stay. 
13
Admission Hr
Not required
14
Admission Type
Not required
15
Admission Source
Enter a code indicating the point of origin for this 
admission or visit. Refer to the NUBC Instruction Manual 
for code values.
16
DHR
Not required
17
Stat
Enter the code indicating the disposition or discharge status 
of the resident at the end of the period covered on this bill, 
as reported in Field 6, Statement Covers Period. 
Refer to the NUBC Instruction Manual for code values.
18-28
Condition Codes
Not required
29
ACDT State
Not required
30
(Unnamed)
Not required
31-34
Occurrence 
Code/Date
Not required
35-36
Occurrence Span 
From/Through
If applicable, enter the occurrence span code from the list 
below, for any medical leave of absence (MLOA) days or 
nonmedical leave of absence (NMLOA) days along with 
the associated dates of leave. 
71	Prior stay dates - MLOA
74    First/last visit dates - NMLOA
37
(Unnamed)
Not used 
38
(Unnamed)
Not required
39-41
Value Codes
Code/Amount
Enter value code 24 (Medicaid rate code) along with the 
total charges amount of the claim. (Note: The actual payer 
is DTA, but the Commonwealth uses the MassHealth 
claims payment system to process claims on behalf of 
DTA.)
Enter value code 80 for covered days and the number of 
covered days.
If a resident has a resident liability amount, on a separate 
line, enter value code FC and the resident liability amount.
42 (Lines 
1-22)
Rev Cd
Enter the applicable revenue code(s) as described below.
*	Enter revenue code 100 for room and board days for 
residential care homes.
*	Enter revenue code 183 for nonmedical-leave-of-
absence (NMLOA) days.  
*	Enter revenue code 185 for medical-leave-of-absence 
(MLOA) days.
If a resident has MLOA days or NMLOA days in the 
statement billed period, bill the revenue code and the 
number of room-and-board days (excluding MLOA and 
NMLOA days) on the first line with the number of room 
and board days in Field 46. Then, enter the revenue code 
for the MLOA days or NMLOA days on a different line 
with the appropriate revenue code and number of days in 
Field 46. The total number of room-and-board days and 
MLOA or NMLOA days should equal the number of 
covered days. When billing only for leave-of-absence days, 
do not include revenue code 100 for room-and-board days.
42 (Line 
23)
Rev Cd
Enter revenue code 0001. 
43 (Lines 
1-22)
Description
Enter the appropriate description of the revenue code.
43 (Line 
23)
Page__of __
Only single-page UB-04 claims are accepted. This should 
always be Page 1 of 1.
44 (Lines 
1-22)
HCPCS/ 
Rates/HIPPS Code
Not required
45 (Lines 
1-22)
Service Date
Not required
45 (Line 
23)
Creation Date
Enter the date the claim form was submitted for 
reimbursement. This date cannot be earlier than the dates 
listed in field 6 of the UB-04.
This is a required field.
46 (Lines 
1-22)
Service Units
For each claim line, enter the total number of covered 
accommodation days defined by revenue code 
requirements.
47 (Lines 
1-22)
Total Charges
For each claim line, enter the total charges that apply to the 
revenue codes entered in lines 1-22 in field 42.
Do not deduct the resident’s resident-liability amount from 
the total charge of the claim.
47 (Line 
23)
Total Charges 
(Totals)
Enter the total of all entries in this column on the bottom 
line.
This is a required field.
48 (Lines 
1-22)
Non-Covered 
Charges
Not required
48 (Line 
23)
Non-Covered 
Charges (Totals)
Not required
49 (Lines 
1-23)
(Unnamed)
Not used
50A-C
Payer Name
Enter “MassHealth.” (Note: The actual payer is DTA, but 
the Commonwealth uses the MassHealth claims payment 
system to process claims on behalf of DTA.) 
51A-C
Health Plan ID
Not required
52A-C
Rel Info 
If applicable, enter the appropriate code for release of 
information. Refer to the NUBC Instruction Manual for 
code values.
53A-C
Asg. Ben.
Not required
54A-C
Prior Payments
Not required 
55A-C
Est. Amount Due
Enter the amount estimated by the residential care home to 
be due from the indicated payer (estimated responsibility 
minus prior payments).
56
NPI
Enter the residential care home’s 10-digit national provider 
identifier (NPI) if applicable. Residential care homes 
should enter the NPI only if they have an NPI on file with 
the MassHealth claims payment system. Otherwise, they 
must leave it blank.
57A-C
Other Prv
If you do not have an NPI, enter your 10-character 
MassHealth provider ID and service location. 
58A-C
Insured’s Name
Enter the name of the resident.
59A-C
P. Rel
Enter “self.” 
60A-C
Insured’s Unique ID
Enter the resident’s 12-character MassHealth ID. (Note: 
The actual payer is DTA, but the Commonwealth uses the 
MassHealth claims payment system to process claims on 
behalf of DTA.)
61A-C
Group Name
Not required
62A-C
Group No.
Not required
63A-B
Treatment 
Authorization Codes
Not required
63C
Treatment 
Authorization Codes
Not required
64A
Document Control 
No. (Line A only)
For Adjustments: 
When requesting an adjustment to paid claims, and the 
frequency code on the Type of Bill is “7” (Replacement of 
Prior Claim), enter an “A” followed by the 13-character 
internal control number (ICN) assigned to the paid claim. 
The ICN appears on the remittance advice on which the 
original claim was paid. When submitting an adjustment, 
include all lines that were on the original claim. Correct the 
line that needs to be adjusted. 
For Resubmittals: 
When resubmitting a denied claim, enter an “R” followed 
by the 13-character ICN assigned to the denied claim. The 
ICN appears on the remittance advice on which the 
original claim was denied. 
64B-C
Document Control 
No.
Not required
65
Employer Name
Not required
66
DX 
Enter the qualifier that denotes the version of International 
Classification of Diseases (ICD) reported.
67
(Unnamed)
Enter the ICD-9-CM diagnosis codes describing the 
principal diagnosis. Refer to the NUBC Instruction Manual 
for code values. 
67(A-Q)
(Unnamed)
Enter the ICD-9-CM diagnosis codes corresponding to all 
conditions that coexist at the time of admission, that 
develop subsequently, or that affect the treatment received 
or the length of stay. Refer to the NUBC Instruction 
Manual for code values. 
68 
(Unnamed)
Not used
69
Admit DX
Not required
70(a-c)
Patient Reason DX
Not required
71
PPS Code
Not required 
72(a-c)
ECI
Not required
73
(Unnamed)
Not used 
74
Principal Procedure 
Code/Date
Not required
74 (a-e)
Other Procedure 
Codes/Dates
Not required
75
(Unnamed)
Not used
76
Attending NPI Last 
First
Enter the name and NPI of the physician who is primarily 
responsible for the care of the resident reported in this 
claim.
77
Operating NPI Last 
First
Not required
78-79
Other NPI Last First
Not required
80
Remarks
Not required
81a
CC 
Not required
81b
CC 
Not required
81c
CC 
Not required
81d
CC
Not required

		
Residential Care Home Billing Guide for the UB-04
	
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Residential Care Home Billing Guide for the UB-04

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Residential Care Home Billing Guide for the UB-04

		
Residential Care Home Billing Guide for the UB-04
How to Complete the UB-04 Claim Form (cont.)


December 2011		Page 10