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The UB-04 is a claim form that is utilized for Hospital. Services and select residential services. Please note that these instructions are specifically written to correlate with Partners Behavioral Health Management's Claim. Management System – Alpha MCS. This guide gives detailed line by line instructions on how to complete
ICD-9 procedure codes must be used to identify surgical procedures billed on the UB-04. ? CPT/HCPCS and modifiers must be used to identify other services rendered. COMPLETING THE UB-04 CLAIM FORM. The following instructions explain how to complete the UB-04 claim form and whether a field is. “Required
CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated). R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D. Chapter / Section / Subsection / Title. R. 25/TOC/Completing and Processing the CMS 1450 Data Set. R. 25/50/Uniform Bill (UB) - Form CMS-1450 for Billing (UB-92). R. 25/60/General
Mar 15, 2017 F.33. March 2017. Billing and ReimBuRsement—ResOuRCes. Completing a Paper uB-04 Form (cont.) Form. Locator #. Name. Type. Instructions. 16. dHR (discharge Hour). O. • enter the hour during which the patient was discharged, using two numeric characters. Hours are entered using 24 hour time.
The following provider types may bill electronically or use the UB-04 CMS-1450 paper claim form when requesting payment: Provider Types supports the filed claim. Note: In the case of an audit, facility providers will not be allowed to submit an addendum to the original medical records for finalized claims. EXAMPLE
UB-04 Claim Form Instructions. FORM LOCATOR NAME. INSTRUCTIONS. 1. Billing Provider Name &. Address. Enter the name and address of the hospital/facility submitting the claim. 2. Pay to Address. Pay to address if different than field 1. 3a. Patient Control Number. Enter your facility's unique account number assigned
Instructions for Completing the UB-04 Claim Form. The UB04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics, chronic dialysis and Adult Day Health Care). A UB04 with field descriptions and instructions is included.
CLAIM. Tips for Completing the UB04 (CMS-1450) Claim Form. Page 1 of 17. Field. Field description. Field type Instructions. 1. Facility name, Address,. Telephone Number, and Country. Code. Required. This field contains the complete. Servicing address (the address where the services are being performed/rendered) and
Completing the UB-04 Claim Form. Guidelines for Facility/Institutional Providers. Medica follows national and state uniform billing guidelines for the submission of UB-04 claim forms, although some fields required by Medicare or other payers may not be necessary for. Medica claims. Inside is a blank UB-04 claim form for
Sep 16, 2016 UB-04 CLAIM FORM INSTRUCTIONS. FIELD. NUMBER. FIELD NAME. INSTRUCTIONS. 1. Billing Provider Name &. Address. Enter the name and address of the hospital/facility submitting the claim. 2. Pay to Address. Pay to address if different than field 1. 3a. Patient Control Number. Enter your facility's
     

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