Ub92 Claim Form

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UB92 Claim Form
4
Facility billing name and address
2
3 PATIENT CONTROL NO.
TYPE
OF
BILL
6 STATEMENT COVERS PERIOD
5 FED. TAX NO.
7 COV’D
8 N-C D
9 C-I D
10 L-R D
11
FROM
THROUGH
12 PATIENT NAME
13 PATIENT ADDRESS
AD M I SS IO N
CONDITION CODES
31
14 BIRTHDATE
15 SEX
6 MS
21 D HR
22 STAT
23 MEDICAL RECORD NO.
17 DATE
18 HR
19 TYPE
20 SRC
24
25
26
27
28
29
30
32
OCCURRENCE
33
OCCURRENCE
34
OCCURRENCE
35
OCCURRENCE
36
OCCURRENCE SPAN
37
A
CODE
DATE
CODE
DATE
CODE
DATE
CODE
DATE`
CODE
FROM
THROUGH
B
C
39
VALUE CODES
40
VALUE CODES
41
VALUE CODES
CODE
AMOUNT
CODE
A,MOUNT
CODE
AMOUNT
a
b
c
d
42 REV. CD.
43 DESCRIPTION
44 HCPCS/RATES
45 SERV. DATE
46 SERV. UNITS
47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
50 PAYER
51 PROVIDER NO.
52 REL
53 ASG
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56
INFO
BEN
57
58 INSURED’S NAME
59 P. REL
60 CERT. - SSN - HIC - ID NO.
61 GROUP NAME
62 INSURANCE GROUP NO.
.63 TREATMENT AUTHORIZATION CODES
64 ESC
65 EMPLOYER NAME
66 EMPLOYER LOCATION
67 PRIN. DIAG. CD.
OTHER DIAG. CODES
76 ADM. DIAG, CD.
77 E-CODE
78
68 CODE
69 CODE
70 CODE
71 CODE
72 CODE
73 CODE
74 CODE
75 CODE
304.00
79 P.C.
80
PRINCIPAL PROCEDURE
81
OTHER PROCEDURE
OTHER PROCEDURE
82 ATTENDING PHYS. ID
CODE
DATE
CODE
DATE
CODE
DATE
OTHER PROCEDURE
OTHER PROCEDURE
OTHER PROCEDURE
83 OTHER PHYS. ID
CODE
DATE
CODE
DATE
CODE
DATE
84 REMARKS
OTHER PHYS. ID

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