Tips For Completing The Ub04 (Cms-1450) Claim Form printable pdf download

Tips for Completing the UB04 (CMS-1450)

Claim Form

NOTE: FAILURE TO PROVIDE VALID INFORMATION MATCHING THE INSURED’S ID CARD COULD RESULT IN A

REJECTION OF YOUR CLAIM.

Field

Field description

Field type

Instructions

This field contains the complete Servicing address (the address where

Facility name,

the services are being performed/rendered) and telephone and/or fax

Address, Telephone

Required

number. This must be a street address. Please enter this to match the

Number, and

name and address submitted to Beacon on your credentialing

Country Code

documents.

This field contains the address to which payment should be sent if

Pay-to Name and

Conditional

different from the information in Field 1. Please be sure this matches

Address

what you submitted on your credentialing documents.

Complete this field with the patient account number assigned by the

Patient Control

provider that allows for the retrieval of individual patient financial records.

Conditional

If completed, this number will be included on the Provider’s Summary

Number

Voucher.

In this field, report the patient’s medical record number as assigned by

Medical/Health

Conditional

Record Number

the provider.

This field is for reporting the type of bill for the purposes of third-party

processing of the claim such as inpatient or outpatient. The first digit is a

Type of Bill

Required

leading zero. The second digit is the type of facility. The third digit

classifies the type of care being billed. The fourth digit indicates the

sequence of the bill for a specific episode of care.

Enter the number assigned by the federal government for tax reporting

Federal Tax Number

Required

purposes. This may be either the Tax Identification Number (TIN) or the

Employer Identification Number (EIN).

Statement Covers

Use this field to report the beginning and end dates of service for the

Period “From” and

Required

period reflected on the claim in MMDDYY format.

“Through”

Reserved for

Not

Assignment by the

N/A

Required

NUBC

This field is for the patient’s identification number. Only required if the

Patient Identifier

Conditional

patient’s ID on their identification card is different than the subscriber’s.

This field is for the patient’s last, middle initial, and first name.

Patient Name

Required

This field is for entering the patient’s street address. Please comply with

Patient Address

Required

US Postal service guidelines for all addresses.

This field is for entering the patient’s city.

(unlabeled field)

Required

Tips for Completing the UB04 (CMS-1450) Claim Form

Tips For Completing The Ub04 (Cms-1450) Claim Form

Related Articles

Related forms

Related Categories