Ubo4 2025

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The document provides detailed instructions for completing the UB-04 Claim Form, which is used for billing healthcare services. It outlines the necessary information to be filled in various fields, including provider details, patient information, type of bill, service dates, diagnosis and procedure codes, and payment details. The instructions aim to ensure accurate claim submissions for reimbursement from insurance payers.

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Click ‘Get Form’ to open the ubo4 in the editor.
Begin by entering the Billing Provider Name & Address in the designated fields. This identifies the facility submitting the claim.
If applicable, provide a different Pay to Address in field 2.
In section 3a, input your facility's unique Patient Control Number, followed by the Medical Record Number in section 3b.
For Type of Bill (field 4), enter the four-digit code that corresponds to your facility type and billing classification.
Continue filling out patient details including name, address, birth date, and sex in sections 8 through 11.
Complete admission details such as Admission Date and Hour (fields 12 and 13) using the specified formats.
Finally, review all entries for accuracy before saving or submitting your completed form.

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What is the purpose of the UB-04 form?

The National Uniform Billing Committee (NUBC) approved the UB-04 as the replacement for the UB-92 at its February 2005 meeting. The NUBC is responsible for the design and printing of the UB-04 form.

Who fills out an UB04?

Institutional healthcare providers, such as hospitals, nursing facilities, dialysis centers, home health agencies, hospice providers, PRTFs, swing-bed facilities, all use the UB-04 claim form to bill inpatient and outpatient services and submit claims for reimbursement to insurance companies and other payers.

Who is responsible for approved data elements and codes for UB-04?

Your healthcare provider - You can request a sample UB-04 form from your healthcare provider. They may have a blank copy of the form that you can use as a reference. Commercial printing companies - Many companies specialize in printing medical forms, including the blank UB-04 form.

Who fills out an UB04 form?

Ub 04 Forms - Office Depot.

What is UB04?

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).