April 25, 2024 2:11 am

UB 04 PDF Insurance Claim Form Filler

UB 04 PDF Insurance Claim Form Filler

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
    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

    Here is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

    Need help? Contact support

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