Get Ambulatory Surgery Center's (asc) 2011 Workshop. Converting To Ub-04/837i Claim Format Billing

This guide provides clear and systematic instructions on how to accurately complete the Ambulatory Surgery Center's (ASC) 2011 Workshop form for converting to UB-04/837I claim format billing. It aims to assist users in understanding each section of the form, ensuring a seamless online submission process.

Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in Field 1 with the billing provider's name, address, and telephone number. Ensure that the details match the facility’s official records.
3. Complete Field 2 with the pay-to name and address, if different from the billing provider's information.
4. In Field 3, provide the patient control number and the medical record number assigned by your facility.
5. For Field 4, input the type of bill code to represent the service provided (e.g., outpatient services).
6. In Field 5, enter the federal tax number of the billing provider.
7. Fill in Field 6 with the start and end service dates using the MMDDYY format.
8. Complete Field 8 with the patient's name and any necessary identifiers.
9. Enter the patient’s complete mailing address in Field 9.
10. In Field 10 and Field 11, provide the patient’s birth date and gender.
11. Complete Fields 42 to 81 with the appropriate codes and identifiers as required for the specific services rendered.
12. Finally, review the completed form for accuracy before saving your changes, downloading, printing, or sharing it as necessary.

Get started on completing and submitting your ASC 2011 Workshop billing form online today!