UB 04 PDF Insurance Claim Form Filler

w to Edit and fill out Ub 04 Form Online

Read the following instructions to use CocoDoc to start editing and writing your Ub 04 Form:

• In the beginning, seek the “Get Form” button and tap it.
• Wait until Ub 04 Form is loaded.
• Customize your document by using the toolbar on the top.
• Download your completed form and share it as you needed.The Office of Management and Budget and the National Uniform Billing Committee have approved the UB-04
  claim form, also known as the CMS-1450 form. The UB-04 claim form accommodates the National Provider
  Identifier (NPI) and has incorporated other important changes. Sample UB-04 forms for inpatient and outpatient
  claims can be found on pages 3 and 4.
  The UB-04 claim form and NPI
  The UB-04 claim form includes several fields that accommodate the use of your NPI. Although the form
  accommodates the NPI, you may continue to report your current provider identification numbers in the
  appropriate areas of the form until otherwise notified. If you have obtained your NPIs and submitted them to us,
  you must report them on the UB-04 claim form.
  If you have any questions regarding the UB-04 claim form, the NPI application process, or reporting your NPI to
  us, please call your Network Coordinator or Hospital/Ancillary Services Coordinator or contact Customer Service
  at 1-800-275-2583. UB-04 data field requirements
  Field location
  UB-04 Description Inpatient Outpatient
  1 Provider Name and Address Required Required
  2 Pay-To Name and Address Situational Situational
  3a Patient Control Number Required Required
  3b Medical Record Number Situational Situational
  4 Type of Bill Required Required
  5 Federal Tax Number Required Required
  6 Statement Covers Period Required Required
  7 Future Use N/A N/A
  8a Patient ID Situational Situational
  8b Patient Name Required Required
  9 Patient Address Required Required
  10 Patient Birthdate Required Required
  11 Patient Sex Required Required
  12 Admission Date Required Required, if applicable
  13 Admission Hour Required Required, if applicable
  14 Type of Admission/Visit Required Required
  15 Source of Admission Required Required
  16 Discharge Hour Required N/A
  17 Patient Discharge Status Required Required
  18-28 Condition Codes Required, if applicable Required, if applicable
  29 Accident State Situational Situational
  30 Future Use N/A N/A
  31-34 Occurrence Codes and Dates Required, if applicable Required, if applicable
  35-36 Occurrence Span Codes and Dates Required, if applicable Required, if applicable
  37 Future Use N/A N/A
  38 Responsible Party Name and Address Required, if applicable Required, if applicable
  39-41 Value Codes and Amounts Required, if applicable Required, if applicable
  42 Revenue Code Required Required
  43 Revenue Code Description Required Required
  NDC Code Required, if applicable Required, if applicable
  UB-04 claim form and instructions
  AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey •
  QCC Insurance Company d/b/a AmeriHealth Insurance Company
  2 12.09 www.amerihealth.com
  Field location
  UB-04 Description Inpatient Outpatient
  44 HCPCS/Rates Required, if applicable Required, if applicable
  45 Service Date N/A Required
  46 Units of Service Required Required
  47 Total Charges (By Rev. Code) Required Required
  48 Non-Covered Charges Required, if applicable Required, if applicable
  49 Future Use N/A N/A
  50 Payer Identification (Name) Required Required
  51 Health Plan Identification Number Situational Situational
  52 Release of Info Certification Required Required
  53 Assignment of Benefit Certification Required Required
  54 Prior Payments Required, if applicable Required, if applicable
  55 Estimated Amount Due Required Required
  56 NPI Required Required
  57 Other Provider IDs Optional Optional
  58 Insured’s Name Required Required
  59 Patient’s Relation to the Insured Required Required
  60 Insured’s Unique ID Required Required
  61 Insured Group Name Situational Situational
  62 Insured Group Number Situational Situational
  63 Treatment Authorization Codes Required, if applicable Required, if applicable

  Instructions and help about ub form 04

  hey everyone for this week’s activity we’re going to be completing the CMS 1500 and the UB for claims forms so you have the information that you need listed in the activities and there’s also a document that I added under the handouts tab that has the patient data table in the provider data table located – in the handouts portal of unit 10 so I’m not going to completely fill out all of the information on the two forms that we’re completing but I do at least want to get you started so if you take a look at the UB for one of our first examples is with Abby Addison so essentially all of the different data fields on the you before in the CMS 1500 have specific information entered into each of these you can find more information about what is entered into each and every field in these step-by-step directions for completing there’s tips for completing the CMS 1500 form and also completing the ubo for claims form found under handouts as well so back to the ubo for I have an area here in secti

  FAQs ub 04 revenue codes

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