A Step-by-Step Guide to UB-04 Forms and EDI 837I in Skilled Nursing Facility Billing

 

Skilled Nursing Facilities (SNFs) must navigate complex billing processes to ensure proper reimbursement and sustainable operations. Accuracy, consistency, and compliance are essential when preparing institutional claims, and two of the most important formats used are the UB-04 form and the EDI 837I electronic file.

In SNF billing, choosing the right submission format—and completing it correctly—can make the difference between timely payments and costly delays. While the UB-04 form remains in use for certain payers, the industry is shifting toward the EDI 837I due to its speed, accuracy, and built-in validation features.

UB-04 vs. EDI 837I: Key Differences

Both formats are used to submit institutional claims, but they differ significantly in method and efficiency. The UB-04, also known as CMS-1450, is a paper form that can be mailed or scanned to payers. It is still accepted by some insurance providers but is slower to process due to manual handling and a higher risk of human error.

The EDI 837I is the electronic version of the UB-04. It is transmitted digitally via a clearinghouse or directly to the payer and includes automatic error-checking mechanisms. This electronic method is now preferred by most insurers and complies with HIPAA standards. Using EDI 837I reduces denials, shortens payment cycles, and improves operational efficiency for SNFs.

Step-by-Step Process for Completing SNF Claims

1. Collect Patient Demographics and Insurance Information

Start by accurately collecting the patient’s personal and insurance details. This includes name, date of birth, gender, address, and Medicare/Medicaid or commercial policy numbers. Incomplete or incorrect data at this stage is one of the most common reasons for claim rejections.

2. Enter Facility and Provider Details

Add the SNF’s National Provider Identifier (NPI), Tax ID, and full address. The attending provider’s name and NPI must also be included to ensure the claim is attributed correctly.

3. Document Services Rendered with Standard Codes

List all services provided—such as room and board, physical therapy, wound care, or medication administration—using appropriate revenue codes. Include HCPCS or CPT codes where applicable to describe procedures and supplies accurately.

4. Assign ICD-10 Diagnosis and Procedure Codes

Accurately enter the principal diagnosis first, followed by any secondary conditions. If the patient underwent procedures (e.g., IV therapy, wound debridement), assign the correct ICD-10 procedure codes. These codes explain the necessity of the services billed.

5. Input Charges and Billing Units

Include itemized charges and billing units for each service provided. Examples include daily rates, therapy durations, medication costs, and equipment usage. Each entry must show quantity, unit price, and total charge.

6. Provide Payer Information and Authorization Numbers

Specify the primary, secondary, or tertiary payers. If services require prior authorization, include the authorization number. This ensures compliance with payer policies and helps prevent denials.

7. Validate Claims with Edits and Scrubbing Tools

Before submission, review the claim using automated scrubbing tools to detect missing fields, coding errors, or mismatches. This step is vital for increasing the likelihood of first-pass acceptance.

8. Submit the Claim

Depending on the payer’s preference, submit the claim via the UB-04 paper form or electronically through the EDI 837I format. Electronic submissions are faster, more secure, and preferred by the majority of insurers.

Best Practices in SNF Claim Submission

• Audit every claim: Maintain complete records of all submissions, including remittances and acknowledgments, for compliance and audits.
• Work collaboratively across departments: Coordinate with nursing, pharmacy, and therapy teams to ensure all services are documented and coded properly.
• Adjust workflows per payer requirements: Customize submissions to account for different payer rules, including modifiers, occurrence codes, and formatting standards.
• Use automation where possible: Automate standard entries like provider information to reduce manual data entry errors.
• Reconcile documentation before billing: Ensure that clinical documentation matches billed services to avoid overbilling or underbilling.

Common Mistakes to Avoid

• Neglecting secondary insurance coverage
• Relying solely on automated scrubbing tools without manual checks
• Incorrect discharge status or transfer codes
• Assuming all payers accept electronic formats
• Missing payer-specific deadlines
• Discrepancies between billed codes and supporting documentation

The Advantage of Outsourcing SNF Billing

To handle the complexity of institutional billing and ensure maximum reimbursement, many facilities choose to outsource their RCM functions. Providers offering offshore SNF billing and coding services in India, such as Info Hub Consultancy Services, deliver accurate, efficient billing support with certified professionals and advanced claim management tools. Outsourcing reduces administrative burden, minimizes errors, and ensures compliance with evolving payer requirements—all at a significantly lower cost.

FAQ

1. How are ICD-10 codes used in SNF billing?
ICD-10 codes establish medical necessity and are essential for reimbursement approval on both UB-04 and EDI 837I claims.

2. Do all payers accept electronic claims via EDI 837I?
While most major insurers accept EDI 837I, some smaller or regional payers may still require paper submissions.

3. How does EDI 837I support denial reduction?
The electronic format includes built-in error checks, reducing the likelihood of rejections and speeding up the payment cycle.

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