Get 0 Utah State Dept - Health Utah

Filling out the 0 Utah State Dept - Health Utah form can be simplified with a clear understanding of its components. This guide provides step-by-step instructions to ensure that users can successfully navigate the form's requirements online.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering your National Provider Identifier (NPI) and Tax Identification Number (Tax ID) in the designated fields. Ensure that these identifiers match your Medicaid contract.
3. Fill out the Claim or Encounter Identifier section, ensuring to provide the correct electronic transmitter identification number.
4. In the Billing Provider section, provide the billing provider's name, address, city, state, and ZIP code. Double-check that the address matches the Medicaid contract service location.
5. Complete the Subscriber Information section accurately, ensuring that the subscriber's last name and first name match those on the Medicaid card.
6. Enter the patient’s details, including last name, first name, and Medicaid identification number. It is critical that these match the records held by Medicaid.
7. In the Claim Details section, input the total claim charges, facility type code, and claim frequency code, using the appropriate values provided in the instructions.
8. Add the relevant diagnosis codes and any necessary additional information in the specified fields. Ensure that you provide detailed documentation for any claims adjustments.
9. Review all sections for accuracy, making necessary edits. Once everything is thoroughly checked, save the changes.
10. Download or print the completed form if needed, or share it as required for filing.

Complete your documents online for a streamlined and efficient submission process.