Ub 04 Form Fields
Sample ub 04 forms for inpatient and outpatient claims can be found on pages 3 and 4.
Ub 04 form fields. 1 required enter the billing provider s name street address city state and zip code where the services were performed. Specifications for each form locator field on the ub 04 claim form and whether or not medica. 2 situational enter the billing provider s mailing address if different from field 1.
2 10 2011 10 55 16 am. Billing provider s pay to name address city state zip and id if it is different from field 1. Requires the field be completed.
The cms 1450 ub 04 is used to submit hospital and medical facility charges for inpatient and outpatient services. Ub 04 claim form instructions. Although developed by the centers for medicare and medicaid cms the form has become the standard form used by all insurance carriers.
Filling in each field on the ub 04 claim form is required not required required when applicable or optional when completing a medica claim. All patient details are required id number with prefix last name first name and date of birth. Ub 04 claim form instructions form locator name instructions 1.
The ub 04 uniform billing form is the standard claim form that any institutional provider can use for the billing of medical and mental health claims. Understanding the ub 04 fields form locator 1. Use red drop on ub 04 paper forms only.
Billing provider name street address city state zip telephone fax and country code. Patient control number and. Field number field name instructions 1.
Some may even require a different form. The ub 04 claim form accommodates the national provider identifier npi and has incorporated other important changes. Ub 04 claims data data elements field locators created date.
The chart of instructions uses color to communicate whether. Replacement corrected claims require a type of bill with a frequency code 7 field 4 and claim number in the document control number field 64. It s printed with red ink on white standard paper.
Enter the name and address of the hospital facility submitting the claim. Enter all required data. The ub 04 claim form and npi the ub 04 claim form includes several fields that accommodate the use of your npi.
Claim form also known as the cms 1450 form. 2 pay to address pay to address if different than field 1. Each insurance provider requires different information to be completed.
3a patient control numberenter your facility s unique account number assigned to the patient up to 20 alpha numeric. 3a optional pat control. Item number required field.