To conclude this step, provide the occurrence span codes, name and address of the party responsible, value codes, and amounts. Next, indicate the point of the patient's origin for the admission, their discharge status, and condition codes where applicable. Give the patient's birthday, sex, date of admission, and priority of admission for example, state whether it was an emergency or trauma, as may be the case. Step 2: Fill out the Patient's DetailsĮnter the patient's name, identification number, and address. Fill sections 4-6 with the type of bill, your facility’s federal tax number, and the billing period's duration covered by the statement, respectively. In section 3, make sure you enter the unique patient number. If their pay-to address differs from the first one, provide it in the following area. In the first section, enter the healthcare provider's name and address. The following is a step-by-step to guide you on filling out the form successfully: Step 1: Fill out the Provider Data As a result, exercise the utmost care in completing the form. Satisfactory filling of the UB 04 form leads to immediate results in compensation claims. Patient's details such as birthdate and address.Information Required on the UB 04 Claim Formīefore receiving money in compensation for rendered services as a healthcare facility, you have to provide the following information appropriately: IHS and Tribally-owned and/or operated 638 facilities can also submit claims requesting reimbursement at the All-Inclusive Rate using the UB 04. Dialysis clinics, nursing homes, free-standing birthing centers, residential treatment centers, and hospice services are all billed using the UB 04 claim form. A UB 04 Form is a document used to bill for all inpatient, outpatient, and emergency room services.
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