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What is a UB 4?

The UB-04 uniform medical billing form is the standard claim form that any institutional provider can use for the billing of inpatient or outpatient medical and mental health claims. It is a paper claim form printed with red ink on white standard paper.

What is Box 39 on UB04?

Box 39-41; a-d \u2013 Value codes and amounts: (Optional) Use these locators to indicate codes and amounts essential to the proper adjudication of the submitted claim. Each form locator contains a three digit field in which to key the indicator code, and a larger free text field in which to designate an applicable amount.

What goes in box 76 on UB04?

76 Attending Provider Names and Identifiers Required This field is for reporting the name and identifier of the provider with the responsibility for the care provided on the claim.

What goes in box 57 on UB04?

57 Other Provider Identifier\u2013Billing Provider Not Required The unique provider identifier assigned by the health plan is reported in this field.

What goes in box 17 on a UB04?

Policy: Field Locator 17 of the UB-04 and its electronic equivalence is a required field on all institutional claims. This code indicates the disposition or discharge status of the beneficiary on the submitted claims.

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What goes in box 59 on UB04?

59. Patient's Relation to Insured Enter the code for the patient's relationship to the insured. 60. Insured's Unique Identifier Enter recipient's nine-digit Medical Assistance ID.

What are the four sections of the UB-04 claim form?

Section 1: Credentialing. Section 2: Contracting. Section 3: Hospital Inpatient Notifications. Section 4: Transfer of Patients to/from Facilities. Section 5: Hospital Bill Audits. Section 6: UB-04 (CMS 1450) Guidelines. Section 7: Interim Bills and Late Charges. Section 8: Sample UB-04 (CMS 1450) Claim Form. Section 9:

What are the four sections of the UB-04 claim form?

Section 1: Credentialing. Section 2: Contracting. Section 3: Hospital Inpatient Notifications. Section 4: Transfer of Patients to/from Facilities. Section 5: Hospital Bill Audits. Section 6: UB-04 (CMS 1450) Guidelines. Section 7: Interim Bills and Late Charges. Section 8: Sample UB-04 (CMS 1450) Claim Form. Section 9:

What is a UB-04 form quizlet?

the standard claim form used by physician's offices, health-care providers to bill for services, UB-04 claim form. Also known as the CMS-1450. Claim form used by hospitals and medical facilities for billing procedures and services. Allows for revenue codes.

What goes in box 57 on UB04?

57 Other Provider Identifier\u2013Billing Provider Not Required The unique provider identifier assigned by the health plan is reported in this field.

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What goes in box 57 on UB04?

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