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

Completing The New Ub-04 Claim Form Page 3

In field 54, only enter the “amount paid” by the insurer and

do not include the “contractual allowance.”

If this box includes the “contractual allowance,” the

“contractual allowance” will be counted as part of the

insurance payment and be deducted from what EDS

reimburses. EDS will pay only up to the Medicare Part B

rate after deducting what the primary insurance paid.

54. PRIOR PAYMENTS*

If a service submitted involves other insurance, it must be

submitted as one detail claim to appropriately process the

payment from the insurance company.

If there are several services provided on the same day that

involve insurance payments, you will need to submit a

separate claim for each service (line) item showing the other

insurance payment received in field 54 on each claim.

Enter the amount due after deducting any amount entered in

55. EST. AMOUNT DUE

field locator 54 from the total entered at the bottom of

column 47.

56. NPI*

Enter the NPI number of the billing provider.

57a. TAXONOMY CODE(S)*

Enter Provider Taxonomy (no space).

60. CERT.-SSN-HIC-ID. NO.*

Enter the patient's Social Security Number.

Enter the Primary Diagnosis Code. Use the appropriate

ICD-9-CM Code. To be reimbursed for Ladies First

67. PRIN. CODE*

procedures, you must use Ladies First ICD-9-CM codes.

(see Fee Schedule tab for ICD-9-CM code list)

Enter the appropriate ICD-9-CM Code for any condition

67 a-q OTHER DIAGNOSIS

other than primary, which requires supplementary treatment.

CODES

To be reimbursed for Ladies First procedures, you must use

Ladies First ICD-9-CM codes.

Enter the individual Attending Physician's NPI number, the

qualifier ZZ and the taxonomy code to the right of the

76. ATTENDING PHYSCIAN*

qualifier box.

Enter any notations relating specific information necessary

80. REMARKS

to adjudicate the claim

Completing The New Ub-04 Claim Form Page 3