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UB04 Form Locator Elements Approved THIN STANDARDS COMMITTEE Standard/Specification UB04 FORM LOCATOR ELEMENTS Version 3 Purpose: The purpose of Standard/Specification UB04 Form Locator Elements,

How to fill out ub04 form locator elements

How to Fill out UB04 Form Locator Elements:

1. Start by gathering all the necessary information required for each locator element on the UB04 form. This includes patient demographics, insurance information, and details about the services provided.
2. Begin with Locator Element 1, which requires the patient's unique identification number. This could be their medical record number or a unique identifier assigned by the healthcare facility.
3. Move on to Locator Element 2, which asks for the patient's last name, first name, and middle initial. Ensure that this information is accurate and matches the patient's records.
4. Locator Element 3 is for the patient's birth date. Enter the day, month, and year in the specified format.
5. Next, fill out Locator Element 4 with the patient's gender, either male (M) or female (F).
6. Locator Element 5 requires the patient's street address, city, state, and ZIP code. Double-check this information for accuracy.
7. In Locator Element 6, enter the patient's relationship to the insured if applicable. Examples include self, spouse, child, or other.
8. Locator Element 7 is for the insured's name. If the patient is the insured, enter their name again. If the patient is a dependent, enter the primary insured's name.
9. For Locator Element 8, provide the insured's unique identification number. This could be their social security number or a designated insurance identification number.
10. Move on to Locator Element 9, which asks for the insured's employer name or school name if applicable. If the patient is the insured, leave this field blank.
11. Locator Element 10 requires the insured's address, including street, city, state, and ZIP code. Enter this information accurately.
12. Complete Locator Elements 11-15 based on the specific insurance coverage details. These elements include the insurance plan name, the group number, the insurance type, the prior authorization number if required, and the patient's birth date if different from Locator Element 3.
13. Finally, for Locator Element 16, provide the diagnosis-related group (DRG) code if applicable. This code helps classify the patient's diagnosis and determines the reimbursement amount.

Who Needs UB04 Form Locator Elements:

1. Healthcare providers and facilities, such as hospitals, clinics, and skilled nursing facilities, need to fill out UB04 forms with accurate and complete locator elements.
2. Insurance companies and third-party payers also require UB04 forms to process and reimburse healthcare claims.
3. Patients may not directly interact with the UB04 form or its locator elements, but their healthcare records and billing information rely on these elements being filled out correctly by the relevant parties.

For pdfFiller’s FAQs

What is ub04 form locator elements?

The UB04 form locator elements are specific fields on the UB-04 claim form used to report information about the patient, provider, and services provided.

Who is required to file ub04 form locator elements?

Healthcare providers, hospitals, and other facilities that submit claims for reimbursement using the UB-04 form are required to complete the locator elements.

How to fill out ub04 form locator elements?

UB04 form locator elements should be filled out accurately and completely according to the instructions provided by the Centers for Medicare and Medicaid Services (CMS).

What is the purpose of ub04 form locator elements?

The purpose of UB04 form locator elements is to ensure that all necessary information for processing a claim is included in a standardized format.

What information must be reported on ub04 form locator elements?

Information such as patient demographics, dates of service, diagnosis codes, procedure codes, and provider information must be reported on UB04 form locator elements.

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