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D M 71 PPS E N ECI F O 76 ATTENDING G P NPI LAST c. d. e. 77 OPERATING 81CC UB-04 CMS-1450 APPROVED OMB NO. 0938-0997 NUBC National Uniform Billing Committee QUAL FIRST 80 REMARKS H Q THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. UB-04 NOTICE THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM MAY SERVE AS THE BASIS FOR CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON...
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How to fill out ub04 form

01
To fill out a UB04 form, start by entering the patient's information in the designated fields. This includes their name, address, date of birth, and insurance information.
02
Next, identify and provide the specific details about the healthcare facility where the services were rendered. This includes the facility name, address, and identification number.
03
Indicate the relevant dates for the services provided, such as the date of admission, discharge, or transfer.
04
Include the diagnostic and procedural information for the services rendered. This may involve identifying the primary diagnosis, any secondary diagnoses, and the corresponding ICD-10 codes. Additionally, include the CPT/HCPCS codes for each procedure or service provided.
05
Specify the type of bill code that corresponds to the healthcare service being billed.
06
Include any remarks or additional documentation that may support the claim, if applicable.
07
Review the completed form for accuracy and ensure that all required fields have been filled out correctly.
Regarding who needs the UB04 form:
01
Healthcare facilities, such as hospitals, nursing homes, and rehabilitation centers, typically utilize the UB04 form for billing purposes.
02
Health insurance companies and government payers, such as Medicare and Medicaid, require the UB04 form to process and adjudicate claims.
03
Medical billing professionals or individuals responsible for the financial aspects of healthcare organizations often need to complete the UB04 form.
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