Ub 92 Form - Uniform Bill Template (Page 2 of 2) in pdf

UNIFORM BILL:

NOTICE: ANYONE WHO MISREPRESENTS OR FALSIFIES ESSENTIAL

INFORMATION REQUESTED BY THIS FORM MAY UPON CONVICTION BE

SUBJECT TO FINE AND IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW.

Certifications relevant to the Bill and Information Shown on the Face

For CHAMPUS purposes:

Hereof: Signatures on the face hereof incorporate the following

This is to certify that:

certifications or verifications where pertinent to this Bill:

(a)

the information submitted as part of this claim is true, accurate and

If third party benefits are indicated as being assigned or in participation

complete, and, the services shown on this form were medically

status, on the face thereof, appropriate assignments by the insured/

indicated and necessary for the health of the patient;

beneficiary and signature of patient or parent or legal guardian

covering authorization to release information are on file.

(b)

the patient has represented that by a reported residential address

Determinations as to the release of medical and financial information

outside a military treatment center catchment area he or she does not

should be guided by the particular terms of the release forms that

live within a catchment area of a U.S. military or U.S. Public Health

were executed by the patient or the patient’s legal representative.

Service medical facility, or if the patient resides within a catchment

The hospital agrees to save harmless, indemnify and defend any

area of such a facility, a copy of a Non-Availability Statement (DD

insurer who makes payment in reliance upon this certification, from

Form 1251) is on file, or the physician has certified to a medical

and against any claim to the insurance proceeds when in fact no

emergency in any assistance where a copy of a Non-Availability

valid assignment of benefits to the hospital was made.

Statement is not on file;

If patient occupied a private room or required private nursing for

(c)

the patient or the patient’s parent or guardian has responded directly

medical necessity, any required certifications are on file.

to the provider’s request to identify all health insurance coverages,

and that all such coverages are identified on the face the claim except

Physician’s certifications and re-certifications, if required by contract

those that are exclusively supplemental payments to CHAMPUS-

or Federal regulations, are on file.

determined benefits;

For Christian Science Sanitoriums, verifications and if necessary re-

(d)

the amount billed to CHAMPUS has been billed after all such coverages

verifications of the patient’s need for sanitorium services are on file.

have been billed and paid, excluding Medicaid, and the amount billed

to CHAMPUS is that remaining claimed against CHAMPUS benefits;

Signature of patient or his/her representative on certifications,

authorization to release information, and payment request, as required

(e)

the beneficiary’s cost share has not been waived by consent or failure

be Federal law and regulations (42 USC 1935f, 42 CFR 424.36, 10

to exercise generally accepted billing and collection efforts; and,

USC 1071 thru 1086, 32 CFR 199) and, any other applicable contract

regulations, is on file.

(f)

any hospital-based physician under contract, the cost of whose

services are allocated in the charges included in this bill, is not an

This claim, to the best of my knowledge, is correct and complete and

employee or member of the Uniformed Services. For purposes of this

is in conformance with the Civil Rights Act of 1964 as amended.

certification, an employee of the Uniformed Services is an employee,

Records adequately disclosing services will be maintained and

appointed in civil service (refer to 5 USC 2105), including part-time or

necessary information will be furnished to such governmental

intermittent but excluding contract surgeons or other personnel

agencies as required by applicable law.

employed by the Uniformed Services through personal service

contracts. Similarly, member of the Uniformed Services does not apply

For Medicare purposes:

to reserve members of the Uniformed Services not on active duty.

If the patient has indicated that other health insurance or a state

(g)

based on the Consolidated Omnibus Budget Reconciliation Act of

medical assistance agency will pay part of his/her medical expenses

1986, all providers participating in Medicare must also participate in

and he/she wants information about his/her claim released to them

CHAMPUS for inpatient hospital services provided pursuant to

upon their request, necessary authorization is on file. The patient’s

admissions to hospitals occurring on or after January 1, 1987.

signature on the provider’s request to bill Medicare authorizes any

holder of medical and non-medical information, including employment

(h)

if CHAMPUS benefits are to be paid in a participating status, I agree

status, and whether the person has employer group health insurance,

to submit this claim to the appropriate CHAMPUS claims processor

liability, no-fault, workers’ compensation, or other insurance which is

as a participating provider. I agree to accept the CHAMPUS-

responsible to pay for the services for which this Medicare claim is

determined reasonable charge as the total charge for the medical

made.

services or supplies listed on the claim form. I will accept the

CHAMPUS-determined reasonable charge even if it is less than the

For Medicaid purposes:

billed amount, and also agree to accept the amount paid by CHAMPUS,

combined with the cost-share amount and deductible amount, if any,

This is to certify that the foregoing information is true, accurate, and

paid by or on behalf of the patient as full payment for the listed medical

complete.

services or supplies. I will make no attempt to collect from the patient

I understand that payment and satisfaction of this claim will be

(or his or her parent or guardian) amounts over the CHAMPUS-

from Federal and State funds, and that any false claims, statements,

determined reasonable charge. CHAMPUS will make any benefits

or documents, or concealment of a material fact, may be prosecuted

payable directly to me, if I submit this claim as a participating provider.

under applicable Federal or State Laws.

ESTIMATED CONTRACT BENEFITS

Ub 92 Form - Uniform Bill Template Page 2

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