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Get printable ub 04 form 2012-2024

XONOMY LOOP ====================== LOOP ID Segment Name PRV01 Qualifier PRV02 Qualifier PRV03 Value PRV BI PT ZZ = Taxonomy NM101 Qualifier NM108 Qualifier NM109 Value 85 24 34 = TAX ID = SSN XX 2000A Loop Name = NPI Billing/Pay-To Provider Specialty Information ====================== 837 I ====================== BILLING PROVIDER LOOP ====================== LOOP ID 2010AA LOOP ID Loop Name Segment Name Billing Provider NM1 Segment Name REF01 Qualifier REF SY EI = SS.

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