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How to fill out the DoL UB-04 CMS-1450 online
This guide provides a comprehensive overview of how to properly complete the DoL UB-04 CMS-1450 form online. It is designed to assist you in navigating each section of the form with clarity and confidence.
Follow the steps to complete the form accurately.
- Press the ‘Get Form’ button to access the DoL UB-04 CMS-1450 form and open it in your preferred editor.
- Fill in Block 1 with the complete provider name, address, city, state, and postal code. Include the area code and phone number of your facility.
- Leave Block 2 blank as it is not required.
- In Block 3a, indicate the required type of bill classification using the appropriate three-digit code.
- Type in Block 5 your Federal tax identification number for tax reporting purposes.
- In Block 6, enter the dates for the range of services being billed, from start to end (MM/DD/YY format).
- Block 7 is to capture the number of covered days, which should be printed clearly.
- In Block 8, input the patient's name in the format of last name followed by the first name, ensuring no titles are included.
- Provide the complete patient mailing address in Block 9.
- Enter the patient's birthdate in Block 10 using MM/DD/YY format.
- Specify the sex of the patient using 'M' for male or 'F' for female in Block 11.
- Block 12 requires the date of admission. Enter this information in MM/DD/YY format.
- Record the admission hour code in Block 13, which is required for inpatient admissions.
- Indicate the source of admission in Block 14, which is also necessary for inpatient services.
- Input the patient's status code on the last day of the billing period in Block 16.
- Complete the remaining blocks following the specific requirements outlined for each, ensuring to use the correct codes and dates.
- Once all fields are filled out, you can save your changes, download the completed form, or print it for submission.
Start filling out your documents online to streamline your process today!
History of the CMS-1500 In 1990, the CMS-1500 changed the form to red ink print to promote the scanning of claims. Later, further changes were made in order to accommodate the National Provider Identifier (NPI).
Fill DoL UB-04 CMS-1450
Instructions for completing OWCP-04 Uniform Billing Form for Medical Services Provided under the FEDERAL EMPLOYEES' COMPENSATION ACT. This form, also known as the UB-04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. Wisconsin Medicaid will begin accepting the new UB-04 (CMS 1450) claim form for UB claims received on and after. An original UB-04 claim form must be completed. • No photocopied or fax claims are accepted. To assure your claim is not rejected or denied, we provide the tips below for accurately completing the UB04 (CMS-1450) claim form. Field. Institutional providers that qualify for a waiver of the electronic claim submission requirement use the CMS-1450 (aka UB-04) form to bill Medicare.
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