Get Ub-04 Claim Form Requirements (pdf) - Regence Blueshield

Filling out the UB-04 claim form accurately is essential for the proper processing of healthcare claims with Regence BlueShield. This guide provides clear and detailed instructions to assist users in completing each section of the form efficiently.

Follow the steps to accurately fill out the UB-04 form.

1. Press the ‘Get Form’ button to access the UB-04 claim form and open it in your online editor.
2. In Locator 1, input the provider's name, address, ZIP code, and telephone number as requested.
3. Leave Locator 2 blank, as instructed.
4. Enter the patient's control number in Locator 3 for identification.
5. Select the appropriate type of bill code in Locator 4 using the valid codes listed for inpatient or outpatient services.
6. Provide your federal tax number in Locator 5 to ensure accurate billing.
7. Record the statement covers period in Locator 6, ensuring it is formatted as CCYYMMDD.
8. Fill in the patient's name, including last name, first name, and middle initial in Locator 8.
9. Input the patient's full address in Locator 9.
10. Enter the patient's birth date in Locator 10, following the MMDDCCYY format.
11. Indicate the patient's sex with ‘M’ for male or ‘F’ for female in Locator 11.
12. In Locator 12, input the date the patient was admitted using MMDDCCYY format.
13. Provide the admission hour code in Locator 13; use the valid admission hour codes provided.
14. Select the type of admission in Locator 14 based on the priority of this admission.
15. Indicate the point of origin for the admission or visit in Locator 15 using the relevant code.
16. Complete subsequent locators as instructed, including discharge hour, patient status, condition codes, and any required specifics for the services provided.
17. After completing the form, save your changes, download, print, or share the form as necessary.

Start filling out your UB-04 claim form online today to ensure timely processing of your healthcare claims.