Get Nd Health Enterprise Mmis Ub-04 Claim Form Instructions - Nd

Filling out the ND Health Enterprise MMIS UB-04 Claim Form can be a straightforward process if you follow the instructions carefully. This guide provides users with step-by-step instructions for each section of the form to ensure accurate submission and timely processing of claims.

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

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the billing provider name and address. Ensure that all required fields marked with 'Required' are completed, as missing information will result in claim denial.
3. Enter the patient control number in Field 3a, which is the unique identifier assigned by your organization to the patient. This field is recommended, but not required.
4. Complete Field 4 with the type of bill code. This is required and should accurately reflect the nature of the claim you are submitting.
5. Enter the federal tax number in Field 5, which is necessary for tax reporting purposes.
6. Fill out the statement covers period in Field 6. Provide the service dates accurately to define the time frame for which the claim is relevant.
7. Complete sections for patient information, including name, birth date, and sex. Ensure accuracy here, as these details are crucial for identification.
8. Provide details of the admission, including date and hour (if applicable), as well as discharge status in Fields 13-17. These fields contain required information that must be provided.
9. Add relevant diagnosis codes and procedure codes in the corresponding fields (Fields 66-74). Be careful to include principal and other procedure codes as required.
10. Review your entries and ensure that all 'Required' fields are filled. Check for any additional fields marked as 'Recommended' to enhance your claim’s processing.
11. Once completed, you can save changes, download, print, or share the form as necessary based on your submission preferences.

Complete your ND Health Enterprise UB-04 Claim Form online to ensure timely and accurate processing of your claims.