Ub 92 Hcfa 1450 Form – Fill Out and Use This PDF

The UB-92 HCFA 1450 form, approved under OMB No. 0938-0279, is a crucial document utilized within the healthcare industry to facilitate the billing process for hospital and clinic services. It encompasses detailed fields for patient information, services provided, charge summaries, and insurance details to ensure accurate and efficient billing and reimbursement from insurance providers. If you need to fill out or submit a UB-92 HCFA 1450 form, click the button below to get started today.

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Ub 92 Hcfa 1450 Form PDF Details

Navigating through medical billing and insurance claims can be complex, and the UB-92 (HCFA-1450) form sits at the heart of this process for many healthcare providers and institutions. This essential document, approved under OMB NO. 0938-0279, serves as a standardized billing form used by hospitals, nursing facilities, and other providers of healthcare services to submit claims to Medicare and Medicaid, as well as private insurers. It encompasses critical patient information, including identification, admission details, and insurance coverage, alongside a detailed rundown of the services provided, coded using the Healthcare Common Procedure Coding System (HCPCS), and the associated charges. The form's structure, divided into sections for patient information, medical condition codes, treatment codes, and financial details, ensures a comprehensive account of the patient's encounter with the healthcare system. By capturing this breadth of data—from the patient's control number and type of bill, through to diagnosis codes, service dates, and charges—the UB-92 form plays a fundamental role in the billing cycle, facilitating the accurate and efficient processing of healthcare claims.

Question	Answer
Form Name	Ub 92 Hcfa 1450 Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	DIAG, 1PLY, ub 92, L-R

Form Preview Example

ST11843 1PLY UB-92

A B C

APPROVED OMB NO. 0938-0279

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.

FROM

THROUGH

12 PATIENT NAME

13 PATIENT ADDRESS

14 BIRTHDATE

15 SEX

16 MS

ADMISSION

21 D HR

22 STAT

23 MEDICAL RECORD NO.

CONDITION CODES

17 DATE

18 HR

19 TYPE

20 SRC

OCCURRENCE

OCCURRENCE SPAN

CODE

DATE

CODE

DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

VALUE CODES

CODE

AMOUNT

CODE

AMOUNT

CODE

AMOUNT

42 REV. CD.

43 DESCRIPTION

44 HCPCS / RATES

45 SERV. DATE

46 SERV. UNITS

47 TOTAL CHARGES

48 NON-COVERED CHARGES

1 2 3 4 5

8 9 10

19 20 21 22 23

50 PAYER	51 PROVIDER NO.	52 REL	53 ASG		54 PRIOR PAYMENTS	55 EST. AMOUNT DUE	56
50 PAYER	51 PROVIDER NO.	INFO		BEN	54 PRIOR PAYMENTS	55 EST. AMOUNT DUE	56

DUE FROM PATIENT

58 INSURED’S NAME

59 P. REL

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

61 GROUP NAME

62 INSURANCE GROUP NO.

63 TREATMENT AUTHORIZATION CODES

64 ESC

65 EMPLOYER NAME

66 EMPLOYER LOCATION

67 PRIN. DIAG. CD.

OTHER DIAG. CODES

76 ADM. DIAG. CD.

77 E-CODE

68 CODE

69 CODE

70 CODE

71 CODE

72 CODE

73 CODE

74 CODE

75 CODE

79 P.C.

PRINCIPAL PROCEDURE

OTHER PROCEDURE

82 ATTENDING PHYS. ID

CODE

DATE

CODE

DATE

CODE

DATE

OTHER PROCEDURE

83 OTHER PHYS. ID

CODE

DATE

CODE

DATE

CODE

DATE

OTHER PHYS. ID

84 REMARKS

85 PROVIDER REPRESENTATIVE

86 DATE

UB-92 HCFA-1450

OCR/ORIGINAL

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

Ub 92 Hcfa 1450 Form – Fill Out and Use This PDF

Ub 92 Hcfa 1450 Form PDF Details

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