Get Ub04 Form

Filling out the UB-04 form online can streamline the billing process for healthcare providers. This guide provides a comprehensive overview of each section of the form, ensuring you complete it accurately to avoid claim issues.

Follow the steps to complete the UB-04 form effectively.

1. Use the ‘Get Form’ button to access the UB-04 form. This will open the form in your preferred editor, allowing you to enter the required information.
2. In the first item field, input the name of the hospital, clinic, or facility, along with the full address and nine-digit ZIP code. The telephone number is optional.
3. Leave the second item field blank as instructed for claims submitted to PHC.
4. For the Patient Control Number (3A), enter the patient's financial record number or account number, if available.
5. Leave the Medical Record Number (3B) blank, as it is not required by PHC.
6. In the TYPE OF BILL (4), enter the appropriate three-character code from the provided list, indicating the facility type.
7. For the Federal Tax Number (5), input the tax identification number as required.
8. In the Statement Covers Period (6), enter the dates of service in MMDDYY format, ensuring the discharge date is in the THROUGH box.
9. Enter the patient's last name, first name, and middle initial (if known) in the Patient Name field (8B). For newborn claims, use the mother's last name followed by 'Baby Boy' or 'Baby Girl'.
10. Provide the patient's date of birth (10) in MMDDYYYY format.
11. Indicate the patient's sex (11) by entering 'M' for male or 'F' for female.
12. Complete the Admission Date and Hour (12-13) by entering the admission date as MMDDYY and the hour in 24-hour format.
13. Enter the Admission Type (14) using the correct numeric code based on the necessity for admission.
14. If applicable, fill in the Admission Source (15) with the correct numeric code if the patient was transferred.
15. Complete the Discharge Hour (16) using the 24-hour format.
16. Provide the patient's status as of the THROUGH date under Status (17) by entering the appropriate numeric code.
17. If condition codes apply (18-24), enter them sequentially starting from the lowest value, following PHC requirements.
18. Incorporate Occurrence Codes and Dates (31-34) as necessary to identify significant claim events.
19. Input the Value Codes and Amount (39-41), focusing on the patient's share of cost and deductibles.
20. Enter the appropriate Revenue Code (42) that corresponds with the services provided.
21. For Total Charges, ensure the correct amount is entered in Box 47 based on the services billed.
22. Finalize your entries by saving your changes. You can then download, print, or share the completed UB-04 form as needed.

Start filling out the UB-04 form online today to ensure efficient billing for your healthcare services.