If you are a healthcare provider, you likely have experience with the ub04 form. This form is used to submit claims for reimbursement from insurance companies, and it is an important tool in your arsenal as a healthcare provider. In this blog post, we will discuss some of the basics of the ub04 form so that you can make sure your submissions are accurate and compliant with all regulations.
Below is the details relating to the form you were seeking to complete. It can tell you the time it will take to finish ub04, what fields you will have to fill in and a few further specific details.
Question | Answer |
---|---|
Form Name | Ub04 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | ub 04 form, ub04 form, software to convert an 837 to ub04 format, form ub 04 |
A
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1 |
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3a PAT. |
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4 TYPE |
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CNTL # |
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OF BILL |
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b. MED. |
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REC. # |
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5 FED. TAX NO. |
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STATEMENT COVERS PERIOD |
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8 PATIENT NAME |
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9 PATIENT ADDRESS |
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10 BIRTHDATE |
11 SEX |
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ADMISSION |
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16 DHR 17 STAT |
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CONDITION CODES |
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29 ACDT 30 |
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DATE |
13 HR 14 TYPE |
15 SRC |
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31 OCCURRENCE |
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OCCURRENCE |
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OCCURRENCE |
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OCCURRENCE |
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39 |
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VALUE CODES |
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VALUE CODES |
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VALUE CODES |
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CODE |
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42 REV. CD. |
43 DESCRIPTION |
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44 HCPCS / RATE / HIPPS CODE |
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45 SERV. DATE |
46 SERV. UNITS |
47 TOTAL CHARGES |
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48 |
49 |
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15 |
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16 |
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17 |
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19 |
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20 |
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21 |
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22 |
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PAGE |
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OF |
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CREATION DATE |
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TOTALS |
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23 |
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50 PAYER NAME |
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51 HEALTH PLAN ID |
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52 REL. |
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53 ASG. |
54 PRIOR PAYMENTS |
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55 EST. AMOUNT DUE |
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56 NPI |
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INFO |
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BEN. |
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57 |
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A |
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OTHER |
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B |
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PRV ID |
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C |
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58 INSURED’S NAME |
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59 P. REL |
60 INSURED’S UNIQUE ID |
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61 GROUP NAME |
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62 INSURANCE GROUP NO. |
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A |
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B |
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C |
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||
63 TREATMENT AUTHORIZATION CODES |
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64 DOCUMENT CONTROL NUMBER |
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65 EMPLOYER NAME |
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A |
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B |
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C
66 |
67 |
A |
|
B |
|
C |
|
D |
|
E |
F |
G |
H |
68 |
DX |
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|||||||||
|
I |
J |
|
K |
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L |
|
M |
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N |
O |
P |
Q |
|
69 ADMIT |
70 PATIENT |
|
A |
B |
|
C |
71 PPS |
|
72 |
A |
B |
C |
73 |
|
|
DX |
REASON DX |
|
CODE |
|
ECI |
|
|||||||
74 |
PRINCIPAL PROCEDURE |
a. |
OTHER PROCEDURE |
b. |
|
OTHER PROCEDURE |
75 |
76 ATTENDING |
NPI |
QUAL |
|
|||
|
CODE |
DATE |
|
CODE |
DATE |
|
CODE |
DATE |
|
|
||||
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LAST |
|
FIRST |
|
c. |
OTHER PROCEDURE |
d. |
OTHER PROCEDURE |
e. |
|
OTHER PROCEDURE |
|
77 OPERATING |
NPI |
QUAL |
|
|||
|
CODE |
DATE |
|
CODE |
DATE |
|
CODE |
DATE |
|
|
||||
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LAST |
|
FIRST |
|
80 REMARKS |
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|
81CC |
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78 OTHER |
NPI |
QUAL |
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a |
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b |
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LAST |
|
FIRST |
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c |
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79 OTHER |
NPI |
QUAL |
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d |
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LAST |
|
FIRST |
|
APPROVED OMB NO. |
™ National Uniform |
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. |
|
|
|
NUBC Billing Committee |
|
Submission of this claim constitutes certification that the billing information as shown on the face hereof is true, accurate and complete. That the submitter did not knowingly or recklessly disregard or misrepresent or conceal material facts. The following certifications or verifications apply where pertinent to this Bill:
1.If third party benefits are indicated, the appropriate assignments by the insured /beneficiary and signature of the patient or parent or a legal guardian covering authorization to release information are on file. Determinations as to the release of medical and financial information should be guided by the patient or the patient’s legal representative.
2.If patient occupied a private room or required private nursing for medical necessity, any required certifications are on file.
3.Physician’s certifications and
4.For Religious
5.Signature of patient or his representative on certifications, authorization to release information, and payment request, as required by Federal Law and Regulations (42 USC 1935f, 42 CFR 424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other applicable contract regulations, is on file.
6.The provider of care submitter acknowledges that the bill is in conformance with the Civil Rights Act of 1964 as amended. Records adequately describing services will be maintained and necessary information will be furnished to such governmental agencies as required by applicable law.
7.For Medicare Purposes: If the patient has indicated that other health insurance or a state medical assistance agency will pay part of his/her medical expenses and he/she wants information about his/her claim released to them upon request, necessary authorization is on file. The patient’s signature on the provider’s request to bill Medicare medical and
8.For Medicaid purposes: The submitter understands that because payment and satisfaction of this claim will be from Federal and State funds, any false statements, documents, or concealment of a material fact are subject to prosecution under applicable Federal or State Laws.
9.For TRICARE Purposes:
(a)The information on the face of this claim is true, accurate and complete to the best of the submitter’s knowledge and belief, and services were medically necessary and appropriate for the health of the patient;
(b)The patient has represented that by a reported residential address outside a military medical treatment facility catchment area he or she does not live within the catchment area of a U.S. military medical treatment facility, or if the patient resides within a catchment area of such a facility, a copy of
(c)The patient or the patient’s parent or guardian has responded directly to the provider’s request to identify all health insurance coverage, and that all such coverage is identified on the face of the claim except that coverage which is exclusively supplemental payments to
(d)The amount billed to TRICARE has been billed after all such coverage have been billed and paid excluding Medicaid, and the amount billed to TRICARE is that remaining claimed against TRICARE benefits;
(e)The beneficiary’s cost share has not been waived by consent or failure to exercise generally accepted billing and collection efforts; and,
(f)Any
(g)Based on 42 United States Code 1395cc(a)(1)(j) all providers participating in Medicare must also participate in TRICARE for inpatient hospital services provided pursuant to admissions to hospitals occurring on or after January 1, 1987; and
(h)If TRICARE benefits are to be paid in a participating status, the submitter of this claim agrees to submit this claim to the appropriate TRICARE claims processor. The provider of care submitter also agrees to accept the TRICARE determined reasonable charge as the total charge for the medical services or supplies listed on the claim form. The provider of care will accept the
SEE http://www. nubc . org/ FOR MORE INFORMATION ON