UB 04 PDF Insurance Claim Form Filler
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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
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
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
FAQs ub 04 revenue codes
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