Completing The New Ub-04 Claim Form (Page 2 of 3) in pdf

Completing The New Ub-04 Claim Form Page 2

10. BIRTH DATE

Enter the date of birth.

Enter the date of admission. Ladies First will not cover

12. ADMISSION DATE*

overnight stays.

13. ADMISSION HR.*

Time patient admitted to facility.

Enter the code indicating the priority of the

admission:

1 - Emergency

14. ADMISSION TYPE*

2 - Urgent

3 - Elective

4 - Nursery

Enter code to identify if condition is related

18-28 CONDITION CODES*

To:

A3 - Ladies First

Enter two digit occurrence code(s), and the corresponding

31-34. OCCURRENCE CD and

date MM/DD/YY when appropriate.

DATE*

Enter the appropriate three digit revenue code for the service

described. To be reimbursed for Ladies First services, this

42. REV. CODE*

must be a revenue code included on the list of covered

services

(see Fee Schedule tab for revenue code list)

The CPT procedure code for lab, radiology or ambulatory

44. HCPCS/RATES *

surgical procedures is required. Ladies First does not cover

HCPCS codes

(see Fee Schedule tab for CPT code list)

Enter the actual date the service was rendered. If the service

was rendered on more than one day, you must bill a separate

45. SERVICE DATE*

charge for each day. A service date must be entered for each

line item submitted for reimbursement.

Enter the quantitative measure of service rendered per

46. SERVICE UNITS*

revenue code.

Enter the total charges pertaining to each revenue code

billed for the current billing period. Add the total charges

47. TOTAL CHARGES*

for all revenue codes being billed and enter at the

bottom of column 47 in the total field.

On 50a, enter the primary payer name. On 50b, enter the

50. PAYER*

other insurance name if applicable.

Enter Ladies First on

50c.

Completing The New Ub-04 Claim Form Page 2

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