Get Completing The Ub-04 Claim Form Guidelines For Facility ... - Medica

Filling out the UB-04 claim form is essential for facility providers to ensure accurate billing and reimbursement. This guide will help you navigate the steps to complete the form correctly, adhering to Medica’s guidelines and requirements.

Follow the steps to complete the UB-04 claim form accurately.

1. Press the ‘Get Form’ button to obtain the UB-04 claim form and open it in your document editor.
2. Begin with field 01, entering the billing provider's name, address, and telephone number in the specified format. Include the provider's name, street address, city, state, ZIP code, and contact details.
3. In field 02, enter the pay-to name and address if it differs from the provider’s address provided in field 01.
4. Fill out fields 03a and 03b with the patient control number and medical/health record number, ensuring both are left-justified.
5. Complete field 04 with the type of bill, using the 4-digit code to reflect the specific bill type when applicable.
6. Input the federal tax number in field 05 as assigned for tax reporting purposes, left-justified up to 10 characters.
7. For field 06, provide the statement covers period, entering beginning and ending service dates in MMDDYY format.
8. Proceed to fill in patient information including name, address, birth date, and sex in fields 08a to 12 as required.
9. Complete fields 38 through 41 with the responsible party's name, value codes, and respective amounts, following specific requirements outlined by Medica.
10. For fields 67 through 75, enter diagnosis and procedure codes as necessary, ensuring to adhere to the guidelines for principal and additional conditions.
11. After all fields are carefully filled, review your entries for accuracy. You can then save changes, download, print, or share the completed form according to your needs.

Start completing your UB-04 claim form online to ensure timely and accurate billing.