Completing The New Ub-04 Claim Form printable pdf download

Completing The New Ub-04 Claim Form

Completing the NEW UB-04 Claim Form

(See sample form in Appendix)

All information on the new UB-04 Claim Form should be typed or legibly printed. Only the 04

version of this form is accepted for processing. The fields listed below are used by EDS when

processing Ladies First claims.

The fields designated by an asterisk (*) are mandatory; other fields are required when applicable.

Fields not listed below are not used by the Ladies First program, and do not need to be

completed.

Note: Only revenue codes on the attached list will be accepted for payment. A “Date of Service”

must be entered for each line item submitted for reimbursement.

To Process LF Electronic 837 Claims

Populate the condition code with a value of

to indicate it is a Ladies First claim.

FIELD LOCATOR

REQUIRED INFORMATION

Enter the Hospital Name and Address as it appears on the

1. UNLABELED FIELD*

Ladies First Provider Enrollment form.

2. UNLABELED FIELD

Enter “Vermont Ladies First Hospital Outpatient”.

For accounting purposes, enter the patient control/medical

3a. PATIENT CONTROL/

record in the field locator. The number may consist of

MEDICAL RECORD NUMBER

up to 24 characters, alpha/numeric. This information will

appear on the RA.

For outpatient values use 131-135 for patient services or 141

4. TYPE OF BILL*

for non-patient services.

6.STATEMENT COVERS

Enter the beginning and ending service dates included on

PERIOD*

this bill. Use MM/DD/CCYY format.

Enter the patient's last name, first name, middle initial.

Please submit names with NO hyphens or spaces in the first

8b. PATIENT’S NAME*

or last name. Correct way: Smith BobbyJoe. Verify correct

spelling of name.

Completing The New Ub-04 Claim Form