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UB-04 claim form and instructions - AmeriHealth

Office of Management and Budget and the National Uniform Billing Committee have approved the UB-04 claim form , also known as the CMS-1450 form . The UB-04 claim form accommodates the National Provider Identifier (NPI) and has incorporated other important changes. Sample UB-04 forms for inpatient and outpatient claims can be found on pages 3 and UB-04 claim form and NPIThe UB-04 claim form includes several fields that accommodate the use of your NPI. Although the form accommodates the NPI, you may continue to report your current provider identification numbers in the appropriate areas of the form until otherwise notified. If you have obtained your NPIs and submitted them to us, you must report them on the UB-04 claim form . If you have any questions regarding the UB-04 claim form , the NPI application process, or reporting your NPI to us, please call your Network Coordinator or Hospital/Ancillary Services Coordinator or contact Customer Service at 1-800-275-2583. UB-04 data field requirementsField location UB-04 DescriptionInpatientOutpatient1 Provider Name and AddressRequiredRequired2 Pay-To Name and AddressSituationalSituational3aPatient Control NumberRequiredRequired3bMedical Record NumberSituationalSituational4 Type of BillRequired Required 5 Federal Tax NumberRequiredRequired6 Statement Covers PeriodRequiredRequired7 Future UseN/AN/A8aPatient IDSituationalSituational8bPatient NameRequiredRequired9 Patient AddressRequiredRequired10 Patient BirthdateReq

Sample UB-04 forms for inpatient and outpatient claims can be found on pages 3 and 4. The UB-04 claim form and NPI The UB-04 claim form includes several fields that accommodate the use of your NPI. Although the form accommodates the NPI, you may continue to report your current provider identification numbers in the appropriate areas of the form ...

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