UB-04 Instruction 2012-2025 free printable template

NUBC National Uniform Billing Committee LIC9213257 QUAL FIRST THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. Green Required/Preferred Black Situational/Required if Applicable/Reserved 80 REMARKS H Q SAMPLE OUTPATIENT UB-04 FORM. New UB-04 Form Instructions The Office of Management and Budget OMB and the National Uniform Billing Committee NUBC previously 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 incorporated other important changes. SAMPLE INPATIENT UB-04 FORM 3a PAT. CNTL b. MED. REC. 5 FED. TAX NO. 8 PATIENT NAME 9 PATIENT ADDRESS a 11 SEX OCCURRENCE CODE DATE c ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT TYPE OF BILL STATEMENT COVERS PERIOD FROM THROUGH b 10 BIRTHDATE CONDITION CODES d e 29 ACDT 30 STATE VALUE CODES AMOUNT 42 REV. The UB-04 form has been used exclusively for institutional billing beginning May 23 2007. Sample UB-04 forms for inpatient...and outpatient services are enclosed. The UB-04 Claim Form and NPI NPI you must continue to report your current provider identification numbers in the appropriate areas of the form. UB-04 Data Field Requirements FIELD LOCATION UB-04 DESCRIPTION INPATIENT OUTPATIENT Provider Name and Address Required Pay-To Name and Address Situational 3a Patient Control Number 3b Medical Record Number Type of Bill Federal Tax Number Statement Covers Period Future Use N/A 8a Patient ID 8b Patient Name Patient...Address Patient Birthdate Patient Sex Admission Date Admission Hour Type of Admission/Visit Source of Admission Discharge Hour Patient Discharge Status 18-28 Condition Codes Required if Applicable Accident State 31-34 Occurrence Code and Dates 35-36 Occurrence Span Codes and Dates Subscriber Name and Address 39-41 Value Codes and Amounts Revenue Code HCPCS/Rates For additional information on the completion of fields please refer to the NUBC Official UB-04 Data Specifications Manual. 2012...PASSPORT HEALTH PLAN PA-111378 Service Date Units of Service Total Charges By Rev. Code Non-Covered Charges Payer Identification Name NPI Release of Info Certification Assignment of Benefit Certification Prior Payments Estimated Amount Due Health Plan IDs Insured s Name Patient s Relation to the Insured Insured s Unique ID Insured Group Name Treatment Authorization Codes Document Control Number Employer Name Diagnosis/Procedure Code Qualifier Principal Diagnosis Code/Other Diagnosis Codes...Admitting Diagnosis Code Patient s Reason for Visit Code PPS Code External Cause of Injury Code Principal Procedure Code/Date Attending Name/ ID-Qualifier Operating ID 78-79 Other ID Remarks Code-Code Field/Qualifiers 0-A0 A1-A4 A5-B0 B1-B2 B3 We would also like to remind you of the requirements for electronic transactions. As a reminder Passport Health Plan strongly recommends the continued use of plan identification numbers in addition to NPI. This form replaced the UB-92 claim form and was...phased in over a transition period beginning March 1 2007. The UB-04 form has been used exclusively for institutional billing beginning May 23 2007. Sample UB-04 forms for inpatient and outpatient services are enclosed. The UB-04 Claim Form and NPI NPI you must continue to report your current provider identification numbers in the appropriate areas of the form. UB-04 Data Field Requirements FIELD LOCATION UB-04 DESCRIPTION INPATIENT OUTPATIENT Provider Name and Address Required Pay-To Name and...Address Situational 3a Patient Control Number 3b Medical Record Number Type of Bill Federal Tax Number Statement Covers Period Future Use N/A 8a Patient ID 8b Patient Name Patient Address Patient Birthdate Patient Sex Admission Date Admission Hour Type of Admission/Visit Source of Admission Discharge Hour Patient Discharge Status 18-28 Condition Codes Required if Applicable Accident State 31-34 Occurrence Code and Dates 35-36 Occurrence Span Codes and Dates Subscriber Name and Address 39-41...Value Codes and Amounts Revenue Code HCPCS/Rates For additional information on the completion of fields please refer to the NUBC Official UB-04 Data Specifications Manual. 2012 PASSPORT HEALTH PLAN PA-111378 Service Date Units of Service Total Charges By Rev. Code Non-Covered Charges Payer Identification Name NPI Release of Info Certification Assignment of Benefit Certification Prior Payments Estimated Amount Due Health Plan IDs Insured s Name Patient s Relation to the Insured Insured s Unique...ID Insured Group Name Treatment Authorization Codes Document Control Number Employer Name Diagnosis/Procedure Code Qualifier Principal Diagnosis Code/Other Diagnosis Codes Admitting Diagnosis Code Patient s Reason for Visit Code PPS Code External Cause of Injury Code Principal Procedure Code/Date Attending Name/ ID-Qualifier Operating ID 78-79 Other ID Remarks Code-Code Field/Qualifiers 0-A0 A1-A4 A5-B0 B1-B2 B3 We would also like to remind you of the requirements for electronic transactions.