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

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

Page 1 of 19. Revised: January 2012. UB-04 claim form requirements. All hospitals participating with Regence are required to submit UB-04 claims in electronic .

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To print and mail your claim form, log in to My Account; choose the Plan Documents tab, then Forms. Next, select the appropriate form for your claim (medical, dental, etc.). To have a claim form mailed to you, call Member Services at the phone number on the back of your member ID card.

When a physician has a private practice but performs services at an institutional facility such as a hospital or outpatient facility, the CMS-1500 form would be used to bill for their services. The CMS-1450 (UB-04) form is the claim form for institutional facilities such as hospitals or outpatient facilities.

The UB-04 (CMS 1450) is a claim form used by hospitals, nursing facilities, in-patient, and other facility providers. ... On the other hand, the HCFA-1500 (CMS 1500) is a medical claim form employed by individual doctors & practices, nurses, and professionals, including therapists, chiropractors, and out-patient clinics.

Box 71 - PPS CODE This is were you will locate the DRG code.

Form Locator 4: Type of Bill (TOB). This is a four-digit code beginning with zero, according to the National Uniform Billing Committee guidelines. Form Locator 5: Federal tax number for your facility. Form Locator 6: Statement from and through dates for the service covered on the claim, in MMDDYY format.

The UB-04 (CMS 1450) is a claim form used by hospitals, nursing facilities, in-patient, and other facility providers. A specific facility provider of service may also utilize this type of form. ... Both forms help to process the medical claim of a patient.

For example, if a surgeon performs a procedure in a facility such as a hospital or ASC, a CMS-1500 will be submitted for the surgeon's services only, while a separate UB-04 form will be submitted for the use of the facility. Both forms will be needed to fully bill out for a procedure.

The Uniform Billing Form known either as the UB-04 or CMS 1450 is the standard for billing all major insurance providers as well as Medicare. The form contains more than 80 lines for important patient information.

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© Copyright 1997-2025
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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
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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