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Pennsylvania Promise Provider Handbook 837 Institutional/UB-04 Claim Form July 2015, Version 2.16 This document contains confidential and proprietary information of the Pennsylvania Promise account

How to fill out 837 institutionalub-04 claim form

How to fill out 837 institutional UB-04 claim form:

1. Gather necessary information: Ensure you have all the relevant patient and healthcare provider details, including their names, addresses, contact information, insurance information, and the patient's medical record number.
2. Complete the patient information section: Fill in the patient's full name, date of birth, gender, and social security number or assigned identification number. Include any relevant patient account numbers or group numbers.
3. Provide healthcare provider details: Enter the billing provider's name, address, national provider identifier (NPI) number, and tax identification number. Include any applicable group or facility numbers.
4. Specify the billing type: Indicate whether the claim is a new submission, a corrected claim, or a void/cancel request.
5. Complete the diagnosis codes: Enter the appropriate diagnosis codes from the International Classification of Diseases (ICD-10) to reflect the patient's medical condition(s).
6. Include procedure codes: Use the correct Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes to describe the medical services provided.
7. Enter revenue codes: Indicate the various services or supplies provided by assigning the appropriate revenue code(s).
8. Include charges and units: Fill in the charges associated with each revenue code and specify the number of units provided.
9. Provide supporting documentation: Include any required documentation, such as operative reports, lab results, or referral forms, to justify the services billed.
10. Review and submit: Double-check all the entered information to ensure accuracy and completeness. Once verified, submit the completed 837 institutional UB-04 claim form to the appropriate insurance payer.

Who needs 837 institutional UB-04 claim form?

1. Healthcare providers: Hospitals, skilled nursing facilities, rehabilitation centers, and other institutional healthcare providers use the 837 institutional UB-04 claim form to bill insurance companies for the services rendered to patients.
2. Insurance companies: Payers require the submission of the 837 institutional UB-04 claim form to process and adjudicate claims from healthcare providers.
3. Patients: Although patients do not directly fill out the form, they are indirectly involved as their medical services and benefits are reflected in the claim form, impacting their insurance coverage and financial obligations.

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What is 837 institutional UB-04 claim form?

The 837 institutional UB-04 claim form is a standardized form used by healthcare providers to bill insurance carriers for services provided to patients.

Who is required to file 837 institutional UB-04 claim form?

Healthcare providers, such as hospitals and skilled nursing facilities, are required to file the 837 institutional UB-04 claim form when billing insurance carriers for services provided to patients.

How to fill out 837 institutional UB-04 claim form?

To fill out the 837 institutional UB-04 claim form, healthcare providers must include patient information, service provided, diagnosis codes, and insurance information.

What is the purpose of 837 institutional UB-04 claim form?

The purpose of the 837 institutional UB-04 claim form is to request payment from insurance carriers for services provided to patients.

What information must be reported on 837 institutional UB-04 claim form?

Information such as patient demographics, dates of service, procedure codes, diagnosis codes, and insurance information must be reported on the 837 institutional UB-04 claim form.