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AS THE BASIS FOR CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW S. 3a PAT. CNTL b. MED. REC. 5 FED. TAX NO. 8 PATIENT NAME 9 PATIENT ADDRESS a 10 BIRTHDATE 11 SEX OCCURRENCE CODE DATE c ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT STATEMENT COVERS PERIOD FROM THROUGH b TYPE OF BILL CONDITION CODES d e 29 ACDT 30 STATE VALUE CODES...
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Form also known as the CMS-1450 form. The UB-04 claim form accommodates the National Provider Identifier NPI and incorporated other important changes. SAMPLE INPATIENT UB-04 FORM 3a PAT. CNTL b. MED. REC. 5 FED. TAX NO. 8 PATIENT NAME 9 PATIENT ADDRESS a 11 SEX OCCURRENCE CODE DATE c ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT TYPE OF BILL STATEMENT COVERS PERIOD FROM THROUGH b 10 BIRTHDATE CONDITION CODES d e 29...
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Provided* Chemotherapy Injected Antineoplastic hormonal injection Drugs/Detail Code Alfa Non-ESRD 1000 units 96402 J0885 X Product Revenue Codes Enter appropriate revenue code for product administered Ex. 250General Pharmacy 636 - Drugs That Require Detail Coding Enter the number of units of each product/service administered* Column 44 Product/Procedure Code s Enter the appropriate HCPCS or CPT codes plus modifiers...
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UB-04 forms for inpatient and outpatient claims can be found on pages 3 and 4. The UB-04 claim form and NPI accommodates the NPI you may continue to report your current provider identification numbers in the appropriate areas of the form until otherwise notified. If you have obtained your NPIs and submitted them to us you must report them on the UB-04 claim form. If you have any questions regarding the UB-04 claim...
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Fillable superior health plan ub 04 form. Description. October 2008 UB-04 Billing Guide for PROMISeTM ICF/MR, ICF/ORCs and State MR Centers Purpose of ...
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