UB-04 Claim Form Instructions Required?

Transcription

1 U-0 lim Form Instrutions Required? Field Lotion Instrutions Required 1 Enter the legl nme of the fility tht rendered the servies nd their omplete physil ddress. Required, if pplies 2 Enter the omplete provider illing ddress if different thn ox 1 Ptient's ount Numer: This is the numer ssigned to the ptient y the Required, if known 3 provider nd n e up to 18-digits long. Leve lnk Enter the pproprite 3-digit type of ill (TO) ode; 1st digit - inditing the type of fility; 2nd digit - inditing the type of re; 3rd digit - inditing the illing sequene. See the Type of ill t for rekdown of these odes. Required, if known 5 Enter the full TRIRE Provider numer for the lotion, if known Enter the dtes the sttement overs: From / Through in the formt MMDDYY (exmple for 12 Jnury 2009) 7 Leve lnk 8 Leve lnk Enter the Ptient's Nme (Lst nme, First Nme, Middle Initil) s it ppers Required on their Militry Identifition rd. Required 9 Enter the ptient's omplete miling street ddress Required Enter the ity for the ptient's miling ddress Required Enter the stte ode for the ptient's miling ddress, if pplile Required d Enter the zip ode for the ptient's miling ddress, if pplile Required e Enter the ountry ode for the ptient's miling ddress, if pplile Required 10 Enter the ptient's irth dte (in the formt MMDDYY) Required 11 Enter M for mle; enter F for femle 12 Enter the dmission dte for the inptient re in the formt MMDDYY Enter the time using 2-digit militry time (00-23) for the time of inptient dmission. Exmple: 00-12:00 midnight - 12:59) Enter the 1 digit ode inditing the priority of the dmission: 1 = Emergeny 2 = Urgent 3 = Eletive = Neworn Enter the 1 digit ode inditing the soure of the dmission: 1 = Physiin Referrl 2 = lini Referrl = Trnsfer from hospitl = Trnsfer from nother helth re fility 8 = ourt/lw Enforement 9 = Informtion not ville Enter the time using 2-digit militry time (00-23) for the time of inptient dishrge. Exmple: 00-12:00 midnight - 12:59) Enter the 2-digit disposition of the ptient s of the "through" dte for the illing period on the lim. 01 = dishrged to home or self re 02 = trnsferred to nother short-term generl hospitl 03 = trnsferred to Skilled Nursing Fility 0 = Trnsferred to n IF 05 = trnsferred to nother type of 0 = dishrged home to re of home helth 07 = left ginst medil dvie 08 = dishrged home under the re of home helth provider 20 = expired 30 = still ptient or expeted to return for outptient servies 31 = still ptient - SNF 32 = still ptient - IF 2 = dishrged/trnsferred to n IRF, distint rehilittion unit of hospitl 5 = dishrged/trnsferred to psyhitri hospitl or distint psyhitri unit of hospitl 18 thru 28 Enter the pproprite 2-digit ondition ode 29 If the servies were the result of n ident, enter the stte/ountry ode. 30 Leve lnk 31 thru 3 Enter the 2-digit ourrene ode used to identify events relting to the ill. 35 nd 3 Enter the 2-digit ourrene spn ode used to identify events relting to the ill.

2 37 Leve lnk Required 38 Enter the sponsor's nme nd omplete ddress. 39 thru 1 Enter the 2-digit vlue odes nd mounts used to identify events relting to the ill. 2 thru 9 This informtion does not need to e populted if n itemized ill/invoie must e tthed with the lim form. 2 22) Enter the pproprite -digit revenue ode. (line 23) Enter 0001 for totl hrges. 3 22) Enter rief desription tht orresponds to the revenue ode entered. (line 23) Enter the numer of pges of the lim form. Enter the pproprite HPS ode for outptient servies 5 22) Enter the dtes of servie for the line. (line 23) Enter the dte the ill ws reted or prepred for sumission in the formt MMDDYY. Enter the numer of units, dys, or visits for the servie. vlue of t lest 1 must e entered. Enter the totl hrge nd urreny for eh servie line. It will e ssumed the 7 mount on the lim will e in the lol urreny unless otherwise speified. 8 22) Leve lnk (line 23) Enter the totl non-overed hrges for ll servie lines. 9 Leve lnk Required, if pplies 50 Primry insurne pyer nme, if not TRIRE, is to e entered in 50 Required, if pplies Seondry insurne pyer nme, if pplile Required, if pplies Tertiry insurne pyer nme, if pplile Required, if pplies 51 Enter the helth pln ID for the pplile insurne; for TRIRE, this would e the 9-digit sponsor numer Required, if pplies Enter the helth pln ID for the pplile insurne; for TRIRE, this would e the 9-digit sponsor numer Required, if pplies Enter the helth pln ID for the pplile insurne; for TRIRE, this would e the 9-digit sponsor numer 52 Leve lnk Required 53 Enter Y if you gree to ept ssignment under the terms of the TRIRE Progrm. Entering Y will uthorize pyment to e sent to the provider of re. Enter N if you do NOT gree to ept ssignment under the terms of the TRIRE progrm - pyment will e sent to the enefiiry diretly. Required, if known 5 Prior Pyments: Enter ny mount of Money tht hs een pid towrds this lim tht the ptient/responsile person or the other helth insurne hs mde. (mth to pproprite line for primry to tertiry.) Required, if known 55 Estimted mount Due: This would e the Totl hrges nd sutrting ox 5; Mke sure eh line mthes for eh field, or. 5 Leve lnk 57 Leve lnk Required 58 For eh line ompleted in field 50, enter the nme of the person who rries the insurne for the ptient. For TRIRE, this will e the sponsor's nme. 59 Enter the reltionship of the ptient. Required 0 Enter the 9-digit sponsor numer; this n e found on the militry ID rd 1 Leve lnk 2 Leve lnk Required, if known 3 If there ws n uthoriztion for the servies, enter the uthoriztion numer here. Leve lnk 5 Leve lnk Leve lnk Required, if known 7 Enter the prinipl/primry ID-9 dignosis ode if the dignosis is not provided on the tthed itemized ill/invoie. Enter dditionl dignosis odes tht existed for the ondition if the dignosis is Required, if known - Q not provided on the tthed itemized ill/invoie. 8 Leve lnk Enter the ID-9 dignosis provided t the time of dmission s stted y the 9 physiin if not provided on the tthed itemized ill/invoie. 70 Leve lnk 71 Leve lnk 72 Leve lnk 73 Leve lnk 7 Enter the prinipl proedure ode nd dte in the formt MMDDYY. thru e Enter ny dditionl proedure odes nd dtes in the formt MMDDYY. 75 Leve lnk 7 thru 79 Leve lnk Required 80 Provider signture (Referene: TOM, hpter 8, Setion ) 81 Leve lnk

3 Type of ill First digit - type of fility: Seond digit - type of re (exept linis nd speil filities) Third digit - frequeny 1 = Hospitl 1 = Inptient (inluding Medire Prt ) 0 = Non-pyment/zero lim 2 = Skilled Nursing 2 = Inptient (Medire Prt only) 1 = dmit thru dishrge lim 3 = Home Helth 3 = Outptient/Visits 2 = Interim - first lim = hristin Siene (Hospitl) = Other 3 = Interim - ontinuing lim 5 = hristin Siene (Extended re) 5 = Intermedite re - Level I = Interim - lst lim = Intermedite re = Intermedite re - Level II 5 = Lte hrge(s) only lim 7 = lini 7 = Intermedite re - Level III = djustment of prior lim 8 = Speil Fility 8 = Swing eds 7 = Replement of prior lim Seond digit - type of re (linis only) 8 = Void/nel of prior lim 9 = Finl lims for home helth 1 = Rurl Helth episode 2 = Free Stnding Renl Dilysis enter = dmission/eletion notie = Hospie/Medire oordinted 3 = Free Stnding re Demonstrtion = ORF or other Reh Fility = Hospie hnge of provider D = Hospie/Medire oordinted 5 = ORF re Demonstrtion Void/nel = MH E = Hospie hnge of ownership F = enefiiry initited djustment 7-8 = Do not use lim 9 = Other G = WF initited djustment lim Seond digit - type of re (speil filities only) H = HF initited djustment lim 1 = Hospie (Non-hospitl sed) I =Intermediry initited djustment 2 = Hospie (Hospitl sed) J = Other initited djustment 3 = multory Surgery enter K = OIG initited djustment = Free Stnding irthing enter M = MSP initited djustment 5 = ritil ess Hospitl P = PRO djustment = Do not use L = djustment lim 7-8 = Do not use 9 = Other

4 1 2 3 PT. TYPE NTL # OF ILL. MED. RE. # 5 FED. TX NO. STTEMENT OVERS PERIOD 7 FROM THROUGH 8 PTIENT NME 9 PTIENT DDRESS d 10 IRTHDTE 11 SEX DMISSION ONDITION ODES 12 DTE HR TYPE SR DHR 29 DT 30 STT STTE e 31 OURRENE 32 OURRENE 33 OURRENE 3 OURRENE 35 OURRENE SPN 3 OURRENE SPN 37 ODE DTE ODE DTE ODE DTE ODE DTE ODE FROM THROUGH ODE FROM THROUGH VLUE ODES 0 VLUE ODES 1 VLUE ODES ODE MOUNT ODE MOUNT ODE MOUNT d 2 REV. D. 3 DESRIPTION HPS / RTE / HIPPS ODE 5 SERV. DTE SERV. UNITS 7 TOTL HRGES 8 NON-OVERED HRGES PGE OF RETION DTE TOTLS PYER NME 51 HELTH PLN ID 52 REL. INFO 53 SG. 5 PRIOR PYMENTS 55 EST. MOUNT DUE 5 NPI EN. 57 OTHER PRV ID 58 INSURED S NME 59 P.REL 0 INSURED S UNIQUE ID 1 GROUP NME 2 INSURNE GROUP NO. 3 TRETMENT UTHORIZTION ODES DOUMENT ONTROL NUMER 5 EMPLOYER NME DX 7 D E F G H I J K L M N O P Q 9 DMIT 70 PTIENT 71 PPS DX RESON DX ODE EI 7 PRINIPL PROEDURE. OTHER PROEDURE. OTHER PROEDURE 75 ODE DTE ODE DTE ODE DTE 7 TTENDING NPI QUL LST FIRST. OTHER PROEDURE d. OTHER PROEDURE e. OTHER PROEDURE ODE DTE ODE DTE ODE DTE 77 OPERTING LST NPI QUL FIRST 80 REMRKS OTHER NPI QUL LST FIRST 8 79 OTHER NPI QUL U-0 MS NU OM PPROVL PENDING d LST FIRST Ntionl Uniform NU illing ommittee LI92257 THE ERTIFITIONS ON THE REVERSE PPLY TO THIS ILL ND RE MDE PRT HEREOF.

5 U-0 NOTIE: THE SUMITTER OF THIS FORM UNDERSTNDS THT MISREPRESENTTION OR FLSIFITION OF ESSENTIL INFORMTION S REQUESTED Y THIS FORM, MY SERVE S THE SIS FOR IVIL MONETRTY PENLTIES ND SSESSMENTS ND MY UPON ONVITION INLUDE FINES ND/OR IMPRISONMENT UNDER FEDERL ND/OR STTE LW(S). Sumission of this lim onstitutes ertifition tht the illing informtion s shown on the fe hereof is true, urte nd omplete. Tht the sumitter did not knowingly or reklessly disregrd or misrepresent or onel mteril fts. The following ertifitions or verifitions pply where pertinent to this ill: 1. If third prty enefits re indited, the pproprite ssignments y the insured /enefiiry nd signture of the ptient or prent or legl gurdin overing uthoriztion to relese informtion re on file. Determintions s to the relese of medil nd finnil informtion should e guided y the ptient or the ptient s legl representtive. 2. If ptient oupied privte room or required privte nursing for medil neessity, ny required ertifitions re on file. 3. Physiin s ertifitions nd re-ertifitions, if required y ontrt or Federl regultions, re on file.. For Religious Non-Medil filities, verifitions nd if neessry reertifitions of the ptient s need for servies re on file. 5. Signture of ptient or his representtive on ertifitions, uthoriztion to relese informtion, nd pyment request, s required y Federl Lw nd Regultions (2 US 1935f, 2 FR 2.3, 10 US 1071 through 108, 32 FR 199) nd ny other pplile ontrt regultions, is on file.. The provider of re sumitter knowledges tht the ill is in onformne with the ivil Rights t of 19 s mended. Reords dequtely desriing servies will e mintined nd neessry informtion will e furnished to suh governmentl genies s required y pplile lw. 7. For Medire Purposes: If the ptient hs indited tht other helth insurne or stte medil ssistne geny will py prt of his/her medil expenses nd he/she wnts informtion out his/her lim relesed to them upon request, neessry uthoriztion is on file. The ptient s signture on the provider s request to ill Medire medil nd non-medil informtion, inluding employment sttus, nd whether the person hs employer group helth insurne whih is responsile to py for the servies for whih this Medire lim is mde. 8. For Mediid purposes: The sumitter understnds tht euse pyment nd stisftion of this lim will e from Federl nd Stte funds, ny flse sttements, douments, or onelment of mteril ft re sujet to proseution under pplile Federl or Stte Lws. 9. For TRIRE Purposes: () The informtion on the fe of this lim is true, urte nd omplete to the est of the sumitter s knowledge nd elief, nd servies were medilly neessry nd pproprite for the helth of the ptient; () The ptient hs represented tht y reported residentil ddress outside militry medil tretment fility thment re he or she does not live within the thment re of U.S. militry medil tretment fility, or if the ptient resides within thment re of suh fility, opy of Non-vilility Sttement (DD Form 1251) is on file, or the physiin hs ertified to medil emergeny in ny instne where opy of Non- vilility Sttement is not on file; () The ptient or the ptient s prent or gurdin hs responded diretly to the provider s request to identify ll helth insurne overge, nd tht ll suh overge is identified on the fe of the lim exept tht overge whih is exlusively supplementl pyments to TRIRE-determined enefits; (d) The mount illed to TRIRE hs een illed fter ll suh overge hve een illed nd pid exluding Mediid, nd the mount illed to TRIRE is tht remining limed ginst TRIRE enefits; (e) The enefiiry s ost shre hs not een wived y onsent or filure to exerise generlly epted illing nd olletion efforts; nd, (f) ny hospitl-sed physiin under ontrt, the ost of whose servies re lloted in the hrges inluded in this ill, is not n employee or memer of the Uniformed Servies. For purposes of this ertifition, n employee of the Uniformed Servies is n employee, ppointed in ivil servie (refer to 5 US 2105), inluding prt-time or intermittent employees, ut exluding ontrt surgeons or other personl servie ontrts. Similrly, memer of the Uniformed Servies does not pply to reserve memers of the Uniformed Servies not on tive duty. (g) sed on 2 United Sttes ode 95()(1)(j) ll providers prtiipting in Medire must lso prtiipte in TRIRE for inptient hospitl servies provided pursunt to dmissions to hospitls ourring on or fter Jnury 1, 1987; nd (h) If TRIRE enefits re to e pid in prtiipting sttus, the sumitter of this lim grees to sumit this lim to the pproprite TRIRE lims proessor. The provider of re sumitter lso grees to ept the TRIRE determined resonle hrge s the totl hrge for the medil servies or supplies listed on the lim form. The provider of re will ept the TRIRE-determined resonle hrge even if it is less thn the illed mount, nd lso grees to ept the mount pid y TRIRE omined with the ost-shre mount nd dedutile mount, if ny, pid y or on ehlf of the ptient s full pyment for the listed medil servies or supplies. The provider of re sumitter will not ttempt to ollet from the ptient (or his or her prent or gurdin) mounts over the TRIRE determined resonle hrge. TRIRE will mke ny enefits pyle diretly to the provider of re, if the provider of re prtiipting provider. SEE FOR MORE INFORMTION ON U-0 DT ELEMENT ND PRINTING SPEIFITIONS