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A Guide for Completing the UB-04 Form The Uniform Bill (UB-04) is the standardized billing form for institutional services. Blue Cross and Blue Shield of Texas offers this guide to help you complete
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How to fill out ub-04 form - bcbstxcom
How to fill out ub-04 form - bcbstxcom?
01
Gather all necessary information and documents such as patient's personal details, insurance information, medical records, and itemized list of services.
02
Start by entering the patient's name, address, and date of birth in the designated fields on the form.
03
Provide the insurance information, including the policyholder's name, policy number, and group number.
04
Indicate the dates of service in the corresponding boxes.
05
List the specific services or procedures provided to the patient in the "Procedure Codes" section. Use the appropriate codes and provide detailed descriptions when necessary.
06
Include any additional charges or fees such as medications, supplies, or diagnostic tests.
07
Fill out the diagnosis codes in the "Diagnosis Codes" section. Use the appropriate codes to indicate the primary reason for the visit and any other relevant diagnoses.
08
Calculate the total charges for the services provided and enter the amount in the "Total Charges" box.
09
Attach any supporting documentation, if required, such as itemized bills or medical records.
Who needs ub-04 form - bcbstxcom?
01
Healthcare providers, such as hospitals, clinics, and skilled nursing facilities, who provide services to patients covered by Blue Cross Blue Shield of Texas (BCBSTX) insurance.
02
Patients who receive medical services from healthcare providers affiliated with BCBSTX.
03
Insurance companies, including BCBSTX, who require the ub-04 form for claims processing and reimbursement purposes.
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