LTC Providers Will Transition to the UB-04 Claim Form

May 16, 2022

To comply with federal Health Insurance Portability and Accountability Act (HIPAA) requirements, the Department of Health Care Services (DHCS) will transition away from the use of local Long Term Care facility service codes and the local Payment Request for Long Term Care (LTC) 25-1 form. Instead, DHCS will process LTC facility claims using the National Uniform Billing Committee (NUBC) UB-04 Data Specifications Manual codes and data elements submitted on a UB-04 claim form.

Once DHCS has determined that LTC providers are ready to accept these changes, they should be prepared to do the following:

  • Submit LTC facility claims using a NUBC UB-04 claim form, one claim form per recipient.

  • Use NUBC UB-04 codes and data elements such as revenue codes, value codes and amounts, and patient discharge status codes.

  • Obtain UB-04 claim forms directly from a vendor such as a commercial retailer or office supply store. Claim forms must include red “drop-out” ink to meet federal Centers for Medicare & Medicaid Services (CMS) standards.

For this update, DHCS will offer various education and training resources to help prepare providers for this transition:

  • A new LTC Claim Form and Code Conversion web page that includes the most up-to-date news about the conversions.

  • Training seminars and webinars featuring instructions on how to complete the UB-04 claim form and the Treatment Authorization Request (TAR).

  • A billing code crosswalk between the local service codes and the NUBC UB-04 codes and data elements.

  • Provider manual instructions on how to complete a UB-04 claim form for LTC facility services.

  • Updates to the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual.

DHCS will maintain current provider billing support services:

  • Technical support with the 837I transaction via the Telephone Service Center (TSC) available at 1-800-541-5555.

  • One-to-one, on-site provider trainings and assistance from a Medi-Cal Provider Field Representative available on request by calling the TSC at 1-800-541-5555.

For updated information on the LTC code and claim form conversion, LTC providers are encouraged to regularly check the LTC Claim Form and Code Conversion web page.