Ub 92 Form PDF Details

In navigating the complexities of healthcare billing, the UB-92 form emerges as a critical document for hospitals and medical facilities. This form, approved under OMB No. 0938-0279, plays a vital role in the processing of medical claims, ensuring that healthcare providers are reimbursed for services rendered. Essentially, the UB-92 encapsulates a wealth of information, from patient identification to details about the medical services provided, including patient control numbers, types of bill, federal tax numbers, and comprehensive data on the patient's stay and treatments received. The form meticulously records patient demographics, admission dates, medical conditions, procedures performed, attending physicians, and insurance coverage details, among others, providing a thorough account of the patient's healthcare journey. Not only does it facilitate a smooth billing process, but it also adheres to regulations set forth by Medicare, Medicaid, and other insurers, thereby underlining the importance of accuracy and completeness in its completion. Misrepresentations or omissions can lead to serious legal consequences, emphasizing the form's role not just in billing and reimbursement, but also in compliance and legal integrity within the healthcare system. Moreover, with certifications and authorizations integrated into its structure, the UB-92 ensures that all necessary permissions for the release of medical and financial information are secured, aligning with federal laws and regulations that protect patient information while enabling necessary disclosures for billing purposes.

QuestionAnswer
Form NameUb 92 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshow to ub92, what is a ub92 form, ub 92 blank, ub82 form

Form Preview Example

ST11843 1PLY UB-92

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A B C

A B C

A B C

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APPROVED OMB NO. 0938-0279

 

 

 

 

 

 

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3 PATIENT CONTROL NO.

 

 

 

 

 

 

 

 

4 TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OF BILL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5 FED. TAX NO.

 

 

 

6 STATEMENT COVERS PERIOD

 

7 COV D.

 

8 N-C D.

9 C-I D.

 

10 L-R D.

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

THROUGH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12 PATIENT NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13 PATIENT ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14 BIRTHDATE

 

15 SEX

16 MS

 

17 DATE

ADMISSION

 

 

 

 

21 D HR

22 STAT

23 MEDICAL RECORD NO.

 

 

 

 

 

 

 

 

 

CONDITION CODES

 

 

 

 

 

 

31

 

 

 

 

 

 

 

 

18 HR

19 TYPE

20 SRC

 

 

 

 

24

 

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37

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32

OCCURRENCE

 

33

 

OCCURRENCE

34

 

OCCURRENCE

35

 

OCCURRENCE

 

36

 

 

 

OCCURRENCE

SPAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

CODE

 

DATE

 

CODE

 

DATE

CODE

 

DATE

CODE

 

DATE

 

CODE

 

FROM

 

THROUGH

 

 

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

39

VALUE CODES

 

40

 

 

VALUE CODES

 

 

41

 

 

VALUE CODES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

CODE

 

AMOUNT

 

CODE

 

 

 

AMOUNT

 

 

 

CODE

 

 

 

AMOUNT

 

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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D

 

42 REV. CD.

43 DESCRIPTION

 

 

 

 

 

 

 

 

 

 

 

44 HCPCS / RATES

 

45 SERV. DATE

46 SERV. UNITS

47 TOTAL CHARGES

 

 

48 NON-COVERED CHARGES

49

 

 

1 2 3 4 5

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8 9 10

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19 20 21 22 23

 

50 PAYER

51 PROVIDER NO.

52 REL

53 ASG

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56

 

 

INFO

 

BEN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

57

 

 

 

 

 

 

 

 

 

 

 

 

DUE FROM PATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

58 INSURED’S NAME

 

 

 

 

59 P. REL

60 CERT. - SSN - HIC. - ID NO.

 

 

 

 

61 GROUP NAME

 

62 INSURANCE GROUP NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

63 TREATMENT AUTHORIZATION CODES

 

 

64 ESC

65 EMPLOYER NAME

 

 

 

 

 

 

 

66 EMPLOYER LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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C

 

67 PRIN. DIAG. CD.

 

 

 

 

 

 

 

 

 

 

OTHER DIAG. CODES

 

 

 

 

 

 

 

 

76 ADM. DIAG. CD.

77 E-CODE

 

78

 

 

 

 

68 CODE

 

69 CODE

70 CODE

 

71 CODE

72 CODE

 

73 CODE

 

 

 

74 CODE

 

75 CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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79 P.C.

 

PRINCIPAL

PROCEDURE

 

81

OTHER PROCEDURE

 

 

OTHER PROCEDURE

 

 

 

82 ATTENDING PHYS. ID

 

 

 

 

 

 

 

 

 

 

 

 

CODE

 

DATE

 

 

CODE

 

 

DATE

 

CODE

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

 

 

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER PROCEDURE

 

 

 

OTHER PROCEDURE

 

 

OTHER PROCEDURE

 

 

 

83 OTHER PHYS. ID

 

 

A

 

 

 

A

 

 

 

 

CODE

 

 

DATE

 

 

CODE

 

 

DATE

 

CODE

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

 

 

 

 

D

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER PHYS. ID

 

 

 

 

 

 

 

 

 

84 REMARKS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

 

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

85 PROVIDER REPRESENTATIVE

 

 

86 DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

x

 

 

 

 

 

 

 

UB-92 HCFA-1450

OCR/ORIGINAL

I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

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It is straightforward to finish the form using this practical guide! Here's what you should do:

1. Begin completing your ub 92 revenue codes with a group of major blank fields. Collect all of the required information and be sure there's nothing forgotten!

Stage no. 1 in submitting what is a ub92 form

2. After filling in the last part, go on to the subsequent step and enter the essential particulars in all these blank fields - PAYER PROVIDER NO PRIOR, REL INFO, ASG BEN, DUE FROM PATIENT, and INSUREDS NAME P REL CERT SSN.

PAYER PROVIDER NO PRIOR, INSUREDS NAME P REL CERT SSN, and DUE FROM PATIENT in what is a ub92 form

3. The third stage is generally straightforward - complete all the blanks in TREATMENT AUTHORIZATION CODES, PRIN DIAG CD, CODE CODE CODE CODE CODE, OTHER DIAG CODES, ADM DIAG CD ECODE, PRINCIPAL PROCEDURE OTHER, CODE DATE CODE DATE CODE DATE, A B, OTHER PROCEDURE OTHER PROCEDURE, CODE DATE CODE DATE CODE DATE, C D E, REMARKS, ATTENDING PHYS ID, OTHER PHYS ID, and OTHER PHYS ID in order to complete the current step.

How to fill out what is a ub92 form portion 3

It is easy to get it wrong when filling in the ADM DIAG CD ECODE, therefore you'll want to take a second look prior to deciding to send it in.

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