Ub04 data field requirements field location ub04 description inpatient outpatient 1 provider name and address required required. Ub04 claim form instructions geisinger health plan. Ub04 data field requirements independence blue cross. Sample ub04 forms for inpatient and outpatient claims can be found on pages 4 and 5. This form, also known as the ub04, is a uniform institutional provider bill.
Claim committee nucc 1500 claim form reference instruction. Enter the correct billing information on another detail line. Im new to coding so maybe there are other uses for this box im not aware of. Sample ub04 forms for inpatient and outpatient claims can be found on pages 3 and 4. Box 660044 dallas, tx 752660044 a division of health care service corporation, a mutual legal reserve company, an independent licensee of the blue cross and blue shield association note. Paper claims submission rejections and resolutions health net. Completing the ub04 claim form guidelines for facilityinstitutional providers medica follows national and state uniform billing guidelines for the submission of ub04 claim forms, although some fields required by medicare or other payers may not be necessary for medica claims. This form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing.
The ub04 claim form is used exclusively for institutional billing and includes several. Box 56 npi facility npi should be submitted in this field. Inside is a blank ub04 claim form for reference, and information on medicas. Guidelines for facilityinstitutional providers medica follows national and state uniform billing guidelines for the submission of ub04 claim forms, although some fields required by medicare or other payers may not be necessary for medica claims. Patients reason for visit at the time of outpatient registration. Inpatient, hospice, and long term care claims require reporting number of covered days value code 80 and noncovered days value code 81. Aarp health insurance plans pdf download medicare replacement pdf download medicare benefits pdf download medicare part b pdf download ub04 box 71 pps code.
This ub04 guide was developed specifically to assist providers with completing the new ub04 claim form during the dual identifier acceptance phase. Although the form accommodates the npi, you may continue to report your current provider identification numbers in the appropriate areas of the form. The ub04 claim form and npi the ub04 claim form includes several fields that accommodate the use of your npi. Inside is a blank ub04 claim form for reference, and information on medica s. Enter 2 digit value code and dollar amount or number of days. If you have any questions regarding the ub04 claim form, please call your network coordinator or customer service at 1800askblue. To submit a claim adjustment, complete the claim form fields below. Inpatient claims ub04 pennsylvania health care cost. Completing the ub04 claim form guidelines for facility. The total charge field eliminates the need for rev code 001. If you have any questions regarding the ub04 claim form, the npi application process.
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