CDPHP UB-04 free printable template

1 43a PAT. CNT # b. MED. REC. #265 FED. TAX NO.8 PATIENT NAME9 PATIENT ADDRESSa10 BIRTHDATE11 SEX31 OCCURRENCE CODE DATE12DATEa admission 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT32 OCCURRENCE CODE DATE33

How to fill out CDPHP UB-04

How to fill out CDPHP UB-04

1. Obtain a blank UB-04 form, which is available from CDPHP or online.
2. Fill out the provider information in the 'Provider Name' field.
3. Enter the patient's information, including full name, address, and date of birth, in the appropriate sections.
4. Indicate the patient’s insurance details, including the policy number and group number.
5. Fill out the details of the services rendered in the 'Description of Services' section.
6. Specify the diagnosis codes using ICD-10 codes in the designated boxes.
7. Include the corresponding procedure codes (CPT/HCPCS) for the services provided.
8. Input the dates of service in the appropriate fields.
9. Double-check all entries for accuracy before submitting.
10. Submit the filled UB-04 form to CDPHP or the appropriate payer.

Who needs CDPHP UB-04?

1. Healthcare providers who bill for inpatient or outpatient services.
2. Hospitals and facilities that require reimbursement for services rendered.
3. Insurance claims departments that process medical billing.

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What is CDPHP UB-04?

CDPHP UB-04 is a standardized claim form used by hospitals and other healthcare facilities in the United States to bill for services provided to patients under various insurance plans, including Medicare and Medicaid.

Who is required to file CDPHP UB-04?

Healthcare facilities such as hospitals, skilled nursing facilities, and other institutional providers are required to file the CDPHP UB-04 when submitting claims for reimbursement to insurance payers.

How to fill out CDPHP UB-04?

To fill out the CDPHP UB-04, providers must provide accurate patient information, including patient demographics, facility details, services rendered, and applicable billing codes, ensuring that all required fields are completed according to the payer's guidelines.

What is the purpose of CDPHP UB-04?

The purpose of CDPHP UB-04 is to facilitate the billing process by providing a uniform format that healthcare facilities use to request payment for services from insurance companies and government programs.

What information must be reported on CDPHP UB-04?

Information that must be reported on CDPHP UB-04 includes patient identification, dates of service, type of service provided, diagnosis codes, procedure codes, the facility's information, charges for services, and other relevant details necessary for processing the claim.