UB 04 Submission Format1

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UB 04 Submission Format1 Powered By Docstoc
					   UB 04 Box/Field No.                 1                    2            3         3a        4         5           6            7          8             9           10         11         12         13         14        15          16         17         18        19        20        21        22          23        24        25        26        27        28        29
                                                                                                                                                     Patient
                                Provider Name,        Pay-to Name,     Patient   Medical             Federal  Statement                  Patient    Address,                                                  Type of                           Patient
                              Address, City, State,   Address, City,   Control   Record    Type of    Tax ID Covers Period               Name -    City, State,    Patient    Patient   Admissio   Admission Admission/ Source of   Discharge   Status    Condition Condition Condition Condition Condition   Condition Condition Condition Condition Condition Condition Accident
UB 04 Box/Field Description       ZIP Phone            State ZIP, ID    No.      Number      Bill    Number From-Through     Unlabeled     ID          ZIP        Birthdate    Sex       n Date      Hour      Visit    Admission     Hour       Code      Codes     Codes     Codes     Codes     Codes       Codes     Codes     Codes     Codes     Codes     Codes     State
   30          31            32           33           34           35           36          37             38              39            40            41         42        43              44             45        46         47      48         49               50             51              52                    53                    54              55            56
                                                                Occurrence   Occurrence                Responsible
                                                                Span Code    Span Code                 Party Name,                                                       Revenue                                                        Non-                     Payer Name-             Release of Information -   Assignment of        Prior Payments -   Estimated    National
            Occurrence   Occurrence   Occurrence   Occurrence     From-        From-                  Address, City,   Value Code -   Value Code - Value Code - Revenue   Code        HCPCS/Rates/HIPPS   Service   Units of    Total  Covered               Primary, Secondary, Health   Primary, Secondary,     Benefits - Primary,   Primary, Secondary, Amount       Provider
Unlabeled   Code/Date    Code/Date    Code/Date    Code/Date     Through      Through     Unlabeled     State ZIP      Code/Amount    Code/Amount Code/Amount    Code   Description      Rate Codes        Date     Service    Charges Charges   Unlabeled         Tertiary      Plan ID        Tertiary          Secondary, Tertiary         Tertiary         Due    Identifier (NPI)
  57               58                     59                    60                     61                    62                      63                 64              65               66          67        67A-Q         68         69        70       71         72          73        74       74a-e      75          76         77        78       79       80        81

 Other      Insured's Name -   Patient's Relationship- Insured's Unique ID -    Insurance Group       Insurance Group      Treatment Authorization   Document    Employer Name -      Diagnosis                                     Admitting Patient's          External Cause            Principal  Other                           Operating   Other    Other            Code -
Provider   Primary, Secondary, Primary, Secondary, Primary, Secondary,           Name - Primary,     Number - Primary,         Code - Primary,        Control   Primary, Secondary,    Version    Principal     Other               Diagnosis Reason      PPS    of Injury Code           Procedure Procedure           AttendingNPI/ NPI/QUAL/ NPI/QUAL/ NPI/QUA         QUAL/CODE/
   ID           Tertiary               Tertiary              Tertiary          Secondary, Tertiary   Secondary, Tertiary     Secondary, Tertiary      Number         Tertiary         Qualifier   Diagnosis   Diagnosis   Unlabeled   Code    for Visit   Code      (E-Code)    Unlabeled Code/Date Code/Date Unlabeled    QUAL/ID        ID        ID      L/ID  Remarks   VALUE

				
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