Ub 04 Form - Tricare Bill Form Page 2

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UB-04 NOTICE:
UB-04 NOTICE:
UB-04 NOTICE:
UB-04 NOTICE:
THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION
THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION
THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION
THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION
OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR
OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR
OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR
OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR
CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE
CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE
CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE
CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE
FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).
FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).
FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).
FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).
Submission of this claim constitutes certification that the billing
Submission of this claim constitutes certification that the billing
Submission of this claim constitutes certification that the billing
Submission of this claim constitutes certification that the billing
(b) The patient has represented that by a reported residential address
(b) The patient has represented that by a reported residential address
(b) The patient has represented that by a reported residential address
(b) The patient has represented that by a reported residential address
information as shown on the face hereof is true, accurate and complete.
information as shown on the face hereof is true, accurate and complete.
information as shown on the face hereof is true, accurate and complete.
information as shown on the face hereof is true, accurate and complete.
outside a military medical treatment facility catchment area he or
outside a military medical treatment facility catchment area he or
outside a military medical treatment facility catchment area he or
outside a military medical treatment facility catchment area he or
That the submitter did not knowingly or recklessly disregard or
That the submitter did not knowingly or recklessly disregard or
That the submitter did not knowingly or recklessly disregard or
That the submitter did not knowingly or recklessly disregard or
she does not live within the catchment area of a U.S. military
she does not live within the catchment area of a U.S. military
she does not live within the catchment area of a U.S. military
she does not live within the catchment area of a U.S. military
misrepresent or conceal material facts. The following certifications or
misrepresent or conceal material facts. The following certifications or
misrepresent or conceal material facts. The following certifications or
misrepresent or conceal material facts. The following certifications or
medical treatment facility, or if the patient resides within a
medical treatment facility, or if the patient resides within a
medical treatment facility, or if the patient resides within a
medical treatment facility, or if the patient resides within a
verifications apply where pertinent to this Bill:
verifications apply where pertinent to this Bill:
verifications apply where pertinent to this Bill:
verifications apply where pertinent to this Bill:
catchment area of such a facility, a copy of Non-Availability
catchment area of such a facility, a copy of Non-Availability
catchment area of such a facility, a copy of Non-Availability
catchment area of such a facility, a copy of Non-Availability
Statement (DD Form 1251) is on file, or the physician has certified
Statement (DD Form 1251) is on file, or the physician has certified
Statement (DD Form 1251) is on file, or the physician has certified
Statement (DD Form 1251) is on file, or the physician has certified
1. If third party benefits are indicated, the appropriate assignments by
1. If third party benefits are indicated, the appropriate assignments by
1. If third party benefits are indicated, the appropriate assignments by
1. If third party benefits are indicated, the appropriate assignments by
to a medical emergency in any instance where a copy of a Non-
to a medical emergency in any instance where a copy of a Non-
to a medical emergency in any instance where a copy of a Non-
to a medical emergency in any instance where a copy of a Non-
the insured /beneficiary and signature of the patient or parent or a
the insured /beneficiary and signature of the patient or parent or a
the insured /beneficiary and signature of the patient or parent or a
the insured /beneficiary and signature of the patient or parent or a
Availability Statement is not on file;
Availability Statement is not on file;
Availability Statement is not on file;
Availability Statement is not on file;
legal guardian covering authorization to release information are on file.
legal guardian covering authorization to release information are on file.
legal guardian covering authorization to release information are on file.
legal guardian covering authorization to release information are on file.
Determinations as to the release of medical and financial information
Determinations as to the release of medical and financial information
Determinations as to the release of medical and financial information
Determinations as to the release of medical and financial information
(c) The patient or the patient’s parent or guardian has responded
(c) The patient or the patient’s parent or guardian has responded
(c) The patient or the patient’s parent or guardian has responded
(c) The patient or the patient’s parent or guardian has responded
should be guided by the patient or the patient’s legal representative.
should be guided by the patient or the patient’s legal representative.
should be guided by the patient or the patient’s legal representative.
should be guided by the patient or the patient’s legal representative.
directly to the provider’s request to identify all health insurance
directly to the provider’s request to identify all health insurance
directly to the provider’s request to identify all health insurance
directly to the provider’s request to identify all health insurance
coverage, and that all such coverage is identified on the face of
coverage, and that all such coverage is identified on the face of
coverage, and that all such coverage is identified on the face of
coverage, and that all such coverage is identified on the face of
2. If patient occupied a private room or required private nursing for
2. If patient occupied a private room or required private nursing for
2. If patient occupied a private room or required private nursing for
2. If patient occupied a private room or required private nursing for
the claim except that coverage which is exclusively supplemental
the claim except that coverage which is exclusively supplemental
the claim except that coverage which is exclusively supplemental
the claim except that coverage which is exclusively supplemental
medical necessity, any required certifications are on file.
medical necessity, any required certifications are on file.
medical necessity, any required certifications are on file.
medical necessity, any required certifications are on file.
payments to TRICARE-determined benefits;
payments to TRICARE-determined benefits;
payments to TRICARE-determined benefits;
payments to TRICARE-determined benefits;
3. Physician’s certifications and re-certifications, if required by contract
3. Physician’s certifications and re-certifications, if required by contract
3. Physician’s certifications and re-certifications, if required by contract
3. Physician’s certifications and re-certifications, if required by contract
(d) The amount billed to TRICARE has been billed after all such
(d) The amount billed to TRICARE has been billed after all such
(d) The amount billed to TRICARE has been billed after all such
(d) The amount billed to TRICARE has been billed after all such
or Federal regulations, are on file.
or Federal regulations, are on file.
or Federal regulations, are on file.
or Federal regulations, are on file.
coverage have been billed and paid excluding Medicaid, and the
coverage have been billed and paid excluding Medicaid, and the
coverage have been billed and paid excluding Medicaid, and the
coverage have been billed and paid excluding Medicaid, and the
amount billed to TRICARE is that remaining claimed against
amount billed to TRICARE is that remaining claimed against
amount billed to TRICARE is that remaining claimed against
amount billed to TRICARE is that remaining claimed against
4. For Religious Non-Medical facilities, verifications and if necessary re-
4. For Religious Non-Medical facilities, verifications and if necessary re-
4. For Religious Non-Medical facilities, verifications and if necessary re-
4. For Religious Non-Medical facilities, verifications and if necessary re-
TRICARE benefits;
TRICARE benefits;
TRICARE benefits;
TRICARE benefits;
certifications of the patient’s need for services are on file.
certifications of the patient’s need for services are on file.
certifications of the patient’s need for services are on file.
certifications of the patient’s need for services are on file.
(e) The beneficiary’s cost share has not been waived by consent or
(e) The beneficiary’s cost share has not been waived by consent or
(e) The beneficiary’s cost share has not been waived by consent or
(e) The beneficiary’s cost share has not been waived by consent or
5. Signature of patient or his representative on certifications,
5. Signature of patient or his representative on certifications,
5. Signature of patient or his representative on certifications,
5. Signature of patient or his representative on certifications,
failure to exercise generally accepted billing and collection efforts;
failure to exercise generally accepted billing and collection efforts;
failure to exercise generally accepted billing and collection efforts;
failure to exercise generally accepted billing and collection efforts;
authorization to release information, and payment request, as
authorization to release information, and payment request, as
authorization to release information, and payment request, as
authorization to release information, and payment request, as
and,
and,
and,
and,
required by Federal Law and Regulations (42 USC 1935f, 42 CFR
required by Federal Law and Regulations (42 USC 1935f, 42 CFR
required by Federal Law and Regulations (42 USC 1935f, 42 CFR
required by Federal Law and Regulations (42 USC 1935f, 42 CFR
424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other
424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other
424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other
424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other
(f) Any hospital-based physician under contract, the cost of whose
(f) Any hospital-based physician under contract, the cost of whose
(f) Any hospital-based physician under contract, the cost of whose
(f) Any hospital-based physician under contract, the cost of whose
applicable contract regulations, is on file.
applicable contract regulations, is on file.
applicable contract regulations, is on file.
applicable contract regulations, is on file.
services are allocated in the charges included in this bill, is not an
services are allocated in the charges included in this bill, is not an
services are allocated in the charges included in this bill, is not an
services are allocated in the charges included in this bill, is not an
employee or member of the Uniformed Services. For purposes of
employee or member of the Uniformed Services. For purposes of
employee or member of the Uniformed Services. For purposes of
employee or member of the Uniformed Services. For purposes of
6. The provider of care submitter acknowledges that the bill is in
6. The provider of care submitter acknowledges that the bill is in
6. The provider of care submitter acknowledges that the bill is in
6. The provider of care submitter acknowledges that the bill is in
this certification, an employee of the Uniformed Services is an
this certification, an employee of the Uniformed Services is an
this certification, an employee of the Uniformed Services is an
this certification, an employee of the Uniformed Services is an
conformance with the Civil Rights Act of 1964 as amended. Records
conformance with the Civil Rights Act of 1964 as amended. Records
conformance with the Civil Rights Act of 1964 as amended. Records
conformance with the Civil Rights Act of 1964 as amended. Records
employee, appointed in civil service (refer to 5 USC 2105),
employee, appointed in civil service (refer to 5 USC 2105),
employee, appointed in civil service (refer to 5 USC 2105),
employee, appointed in civil service (refer to 5 USC 2105),
adequately describing services will be maintained and necessary
adequately describing services will be maintained and necessary
adequately describing services will be maintained and necessary
adequately describing services will be maintained and necessary
including part-time or intermittent employees, but excluding
including part-time or intermittent employees, but excluding
including part-time or intermittent employees, but excluding
including part-time or intermittent employees, but excluding
information will be furnished to such governmental agencies as
information will be furnished to such governmental agencies as
information will be furnished to such governmental agencies as
information will be furnished to such governmental agencies as
contract surgeons or other personal service contracts. Similarly,
contract surgeons or other personal service contracts. Similarly,
contract surgeons or other personal service contracts. Similarly,
contract surgeons or other personal service contracts. Similarly,
required by applicable law.
required by applicable law.
required by applicable law.
required by applicable law.
member of the Uniformed Services does not apply to reserve
member of the Uniformed Services does not apply to reserve
member of the Uniformed Services does not apply to reserve
member of the Uniformed Services does not apply to reserve
7. For Medicare Purposes: If the patient has indicated that other health
7. For Medicare Purposes: If the patient has indicated that other health
7. For Medicare Purposes: If the patient has indicated that other health
7. For Medicare Purposes: If the patient has indicated that other health
members of the Uniformed Services not on active duty.
members of the Uniformed Services not on active duty.
members of the Uniformed Services not on active duty.
members of the Uniformed Services not on active duty.
insurance or a state medical assistance agency will pay part of
insurance or a state medical assistance agency will pay part of
insurance or a state medical assistance agency will pay part of
insurance or a state medical assistance agency will pay part of
(g) Based on 42 United States Code 1395cc(a)(1)(j) all providers
(g) Based on 42 United States Code 1395cc(a)(1)(j) all providers
(g) Based on 42 United States Code 1395cc(a)(1)(j) all providers
(g) Based on 42 United States Code 1395cc(a)(1)(j) all providers
his/her medical expenses and he/she wants information about
his/her medical expenses and he/she wants information about
his/her medical expenses and he/she wants information about
his/her medical expenses and he/she wants information about
participating in Medicare must also participate in TRICARE for
participating in Medicare must also participate in TRICARE for
participating in Medicare must also participate in TRICARE for
participating in Medicare must also participate in TRICARE for
his/her claim released to them upon request, necessary authorization
his/her claim released to them upon request, necessary authorization
his/her claim released to them upon request, necessary authorization
his/her claim released to them upon request, necessary authorization
inpatient hospital services provided pursuant to admissions to
inpatient hospital services provided pursuant to admissions to
inpatient hospital services provided pursuant to admissions to
inpatient hospital services provided pursuant to admissions to
is on file. The patient’s signature on the provider’s request to bill
is on file. The patient’s signature on the provider’s request to bill
is on file. The patient’s signature on the provider’s request to bill
is on file. The patient’s signature on the provider’s request to bill
hospitals occurring on or after January 1, 1987; and
hospitals occurring on or after January 1, 1987; and
hospitals occurring on or after January 1, 1987; and
hospitals occurring on or after January 1, 1987; and
Medicare medical and non-medical information, including
Medicare medical and non-medical information, including
Medicare medical and non-medical information, including
Medicare medical and non-medical information, including
employment status, and whether the person has employer group
employment status, and whether the person has employer group
employment status, and whether the person has employer group
employment status, and whether the person has employer group
(h) If TRICARE benefits are to be paid in a participating status, the
(h) If TRICARE benefits are to be paid in a participating status, the
(h) If TRICARE benefits are to be paid in a participating status, the
(h) If TRICARE benefits are to be paid in a participating status, the
health insurance which is responsible to pay for the services for
health insurance which is responsible to pay for the services for
health insurance which is responsible to pay for the services for
health insurance which is responsible to pay for the services for
submitter of this claim agrees to submit this claim to the
submitter of this claim agrees to submit this claim to the
submitter of this claim agrees to submit this claim to the
submitter of this claim agrees to submit this claim to the
which this Medicare claim is made.
which this Medicare claim is made.
which this Medicare claim is made.
which this Medicare claim is made.
appropriate TRICARE claims processor. The provider of care
appropriate TRICARE claims processor. The provider of care
appropriate TRICARE claims processor. The provider of care
appropriate TRICARE claims processor. The provider of care
submitter also agrees to accept the TRICARE determined
submitter also agrees to accept the TRICARE determined
submitter also agrees to accept the TRICARE determined
submitter also agrees to accept the TRICARE determined
8. For Medicaid purposes: The submitter understands that because
8. For Medicaid purposes: The submitter understands that because
8. For Medicaid purposes: The submitter understands that because
8. For Medicaid purposes: The submitter understands that because
reasonable charge as the total charge for the medical services or
reasonable charge as the total charge for the medical services or
reasonable charge as the total charge for the medical services or
reasonable charge as the total charge for the medical services or
payment and satisfaction of this claim will be from Federal and State
payment and satisfaction of this claim will be from Federal and State
payment and satisfaction of this claim will be from Federal and State
payment and satisfaction of this claim will be from Federal and State
supplies listed on the claim form. The provider of care will accept
supplies listed on the claim form. The provider of care will accept
supplies listed on the claim form. The provider of care will accept
supplies listed on the claim form. The provider of care will accept
funds, any false statements, documents, or concealment of a
funds, any false statements, documents, or concealment of a
funds, any false statements, documents, or concealment of a
funds, any false statements, documents, or concealment of a
the TRICARE-determined reasonable charge even if it is less
the TRICARE-determined reasonable charge even if it is less
the TRICARE-determined reasonable charge even if it is less
the TRICARE-determined reasonable charge even if it is less
material fact are subject to prosecution under applicable Federal or
material fact are subject to prosecution under applicable Federal or
material fact are subject to prosecution under applicable Federal or
material fact are subject to prosecution under applicable Federal or
than the billed amount, and also agrees to accept the amount
than the billed amount, and also agrees to accept the amount
than the billed amount, and also agrees to accept the amount
than the billed amount, and also agrees to accept the amount
State Laws.
State Laws.
State Laws.
State Laws.
paid by TRICARE combined with the cost-share amount and
paid by TRICARE combined with the cost-share amount and
paid by TRICARE combined with the cost-share amount and
paid by TRICARE combined with the cost-share amount and
9. For TRICARE Purposes:
9. For TRICARE Purposes:
9. For TRICARE Purposes:
9. For TRICARE Purposes:
deductible amount, if any, paid by or on behalf of the patient as
deductible amount, if any, paid by or on behalf of the patient as
deductible amount, if any, paid by or on behalf of the patient as
deductible amount, if any, paid by or on behalf of the patient as
full payment for the listed medical services or supplies. The
full payment for the listed medical services or supplies. The
full payment for the listed medical services or supplies. The
full payment for the listed medical services or supplies. The
(a) The information on the face of this claim is true, accurate and
(a) The information on the face of this claim is true, accurate and
(a) The information on the face of this claim is true, accurate and
(a) The information on the face of this claim is true, accurate and
provider of care submitter will not attempt to collect from the
provider of care submitter will not attempt to collect from the
provider of care submitter will not attempt to collect from the
provider of care submitter will not attempt to collect from the
complete to the best of the submitter’s knowledge and belief, and
complete to the best of the submitter’s knowledge and belief, and
complete to the best of the submitter’s knowledge and belief, and
complete to the best of the submitter’s knowledge and belief, and
patient (or his or her parent or guardian) amounts over the
patient (or his or her parent or guardian) amounts over the
patient (or his or her parent or guardian) amounts over the
patient (or his or her parent or guardian) amounts over the
services were medically necessary and appropriate for the health
services were medically necessary and appropriate for the health
services were medically necessary and appropriate for the health
services were medically necessary and appropriate for the health
TRICARE determined reasonable charge. TRICARE will make
TRICARE determined reasonable charge. TRICARE will make
TRICARE determined reasonable charge. TRICARE will make
TRICARE determined reasonable charge. TRICARE will make
of the patient;
of the patient;
of the patient;
of the patient;
any benefits payable directly to the provider of care, if the
any benefits payable directly to the provider of care, if the
any benefits payable directly to the provider of care, if the
any benefits payable directly to the provider of care, if the
provider of care is a participating provider.
provider of care is a participating provider.
provider of care is a participating provider.
provider of care is a participating provider.
SEE h ttp: // ub c .o r g/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS
SEE h ttp: // ub c .o r g/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS
SEE h ttp: // ub c .o r g/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS
SEE h ttp: // ub c .o r g/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS

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