Billing forms

CMS-1500 vs UB-04, when to use each, and their EDI equivalents

Healthcare claims use two standard forms, depending on the type of service and facility.

CMS-1500 (837P)

Attribute	Value
Paper form	CMS-1500
Electronic equivalent	837P (Professional)
Used by	Physicians, clinics, ambulatory surgery centers
Service types	Professional services, office visits, outpatient procedures

The CMS-1500 is the standard for professional claims — services performed by individual providers.

UB-04 (837I)

Attribute	Value
Paper form	UB-04
Electronic equivalent	837I (Institutional)
Used by	Hospitals, SNFs, home health agencies, hospice
Service types	Inpatient stays, outpatient hospital services, facility-based care

The UB-04 is the standard for institutional claims — services provided by facilities.

How RCI determines billing form

The L2 (Facility Type) layer resolves the correct billing form based on the facility’s CCN:

Facility Type	Billing Form	EDI
Short-term hospital (outpatient)	CMS-1500	837P
Short-term hospital (inpatient)	UB-04	837I
Critical Access Hospital	UB-04	837I
Home Health Agency	UB-04	837I
Skilled Nursing Facility	UB-04	837I
Physician office	CMS-1500	837P

curl -X POST https://api-dev.rcintell.com/v1/knowledge/billing-guide \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{"ccn": "170001", "cpt": "99213", "payer": "Medicare"}'

Type of Bill (TOB) codes

UB-04 claims require a Type of Bill code. RCI’s L2 layer resolves the primary TOB code for the facility:

TOB	Description
111	Hospital inpatient (admit through discharge)
131	Hospital outpatient
321	Home health (RAP)
211	Skilled nursing (admit through discharge)
811	Hospice (admit through discharge)