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MARYLAND MEDICALASSISTANCE PROGRAMUB04BILLING INSTRUCTIONSFORFREESTANDING DIALYSIS FACILITY SERVICESUpdated August 14, 2017Rev. 08/14/17UB04 Instructions TABLE of CONTENTSIntroduction 4 Sample UB04 6 UB04
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The sample UB04 is a form used by healthcare providers to bill health insurance companies for services provided to patients.
Healthcare providers, such as hospitals and clinics, are required to file the sample UB04 form when billing health insurance companies.
The sample UB04 form should be filled out with accurate information about the services provided to the patient, including diagnosis codes, procedure codes, and charges.
The purpose of the sample UB04 form is to request payment from health insurance companies for services provided to patients by healthcare providers.
Information such as patient demographics, date of service, type of service provided, diagnosis codes, procedure codes, charges, and insurance information must be reported on the sample UB04 form.
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