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  • Ub-04 Paper Claim Guidelines.xls

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Apr 17, 2008 ... Provider Name and Address. Vendor information for ... WellCare Explanation of Payment. (EOP) ... Provider issued. Provider. 3b. Patient Medical Record #. Situational: provide if one.

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UB-04: Corrections need to be submitted electronically with a type of bill of XX7 or on a paper UB-04 claim form with type of bill XX7 in box 4. All late charges for UB claims must be consolidated into one claim for submission.

Condition codes are a 2-digit numerical or alphanumeric representation of aspects of a patient, services provided, the type of service venue, and/or billing situations that can impact the processing of an institutional claim by a payer. These codes are listed in boxes 18-28 on the UB04 form.

The number of covered days (value code 80) must match the number of units and charges reported for the covered room and board days. Claims to be paid by Per Diem reimbursement should have the appropriate covered days reported to match the authorization.

UB-04 Form Locator code lookup FL 14 - Priority (Type) of Admission/Visit. FL 15 - Point of Origin for Admission or Visit. FL 17 - Patient Status. FL 18-28 - Condition Codes. FL 31-34 - Occurrence Codes. FL 35-36 - Occurrence Span Codes. FL 39-41 - Value Codes. FL 59 - Patient Relationship to Insured.

Yes! You can add any information that the payer may need when adjudicating the claim can be added to appear in box 80 on the UB04 form. If you need additional room, pull down on the right corner (by the blue arrow) and the box will expand to allow for additional room.

71. PPS Code The PPS code assigned to the claim. 72. External Cause of Injury Code Enter the ICD-9-CM diagnosis code pertaining to external cause of injuries.

72. External Cause of Injury Code Enter the ICD-9-CM diagnosis code pertaining to external cause of injuries. 74. Principal Procedure Code and Date Enter the ICD code that identifies the principal procedure performed. Enter the date of that procedure.

* Block 81CC: Enter the taxonomy codes corresponding to providers listed in fields 76-79. Enter the name and payment address of the hospital/provider. Enter the address of the payee if different from the address in Box #1. ** 3a: Enter the patient account number as assigned by the hospital.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232