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Ess Health Plan Name (i.e., WellCare Health Plans) #### Street Name St. City, State #####-#### Must match name and address of health plan responsible for the bill Note, used to print the responsible party's name and address if a window envelope is used. 39-41 Value Codes, Code, Amount Alpha Numeric: Value Code: Alpha Numeric (2) Amount: Numeric (9) Provider The codes and amounts communicate specific information that will affect the claims processing. There are many codes, refer to UB-04.

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