Uben 121 2025

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The document is an enrollment form for the UC Medicare Choice, a Medicare Advantage PPO plan. It outlines the necessary steps for individuals or eligible family members to enroll, including completing separate forms, providing Medicare card copies, and understanding the terms of coverage. Key points include the requirement to have both Medicare Parts A and B, the cancellation of other plans upon enrollment, and instructions for submitting the form to the UC Retirement Administration Service Center.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (100 Votes)
2019	4.3 Satisfied (89 Votes)

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Is place of service 12 inpatient or outpatient?

12 Home Location, other than a hospital or other facility, where the patient receives care in a private residence.

Is bill type 121 inpatient or outpatient?

UC Medicare Choice is a Medicare Advantage PPO plan (also known as Part C) that generally replaces your Medicare coverage and includes Medicare Parts A, B and D. It also offers some extra benefits that Original Medicare does not cover.

How to know if inpatient or outpatient?

An inpatient is a hospital patient who, in most cases, stays in the hospital overnight and meets a set of clinical criteria. Outpatients are people who receive care or hospital services and return home the same day.

What type of bill is 121?

These services are billed under Type of Bill, 121 - hospital Inpatient Part B. A no-pay Part A claim should be submitted for the entire stay with the following information: 110 Type of bill (TOB) All days in non-covered.

What bill type is used for an outpatient claim?

The UB-04 claim form is used to submit claims for outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics and chronic dialysis centers).

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