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4
3a PAT.
CNTL #
b. MED.
REC. #
2
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1
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6
5 FED. TAX NO.
8 PATIENT NAME
9 PATIENT ADDRESS
a
10 BIRTHDATE
11 SEX
31
OCCURRENCE
CODE
DATE
12
DATE
a
c
ADMISSION
13 HR 14 TYPE 15 SRC 16 DHR 17 STAT
32
OCCURRENCE
DATE
CODE
18
19
20
34
OCCURRENCE
CODE
DATE
33
OCCURRENCE
DATE
CODE
7
STATEMENT COVERS PERIOD
FROM
THROUGH
b
b
TYPE
OF BILL
CONDITION CODES
24
22
23
21
35
CODE
38
25
26
36
CODE
OCCURRENCE SPAN
FROM
THROUGH
39
CODE
40
CODE
VALUE CODES
AMOUNT
27
d
28
e
29 ACDT 30
STATE
37
OCCURRENCE SPAN
FROM
THROUGH
41
CODE
VALUE CODES
AMOUNT
VALUE CODES
AMOUNT
a
b
c
d
42 REV. CD.
44 HCPCS / RATE / HIPPS CODE
43 DESCRIPTION
45 SERV. DATE
46 SERV. UNITS
47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
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16
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17
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PAGE
23
OF
TOTALS
CREATION DATE
50 PAYER NAME
52 REL.
INFO
51 HEALTH PLAN ID
53 ASG.
BEN.
23
55 EST. AMOUNT DUE
54 PRIOR PAYMENTS
A
56 NPI
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED’S NAME
62 INSURANCE GROUP NO.
61 GROUP NAME
59 P. REL 60 INSURED’S UNIQUE ID
A
A
B
B
C
C
65 EMPLOYER NAME
64 DOCUMENT CONTROL NUMBER
63 TREATMENT AUTHORIZATION CODES
A
A
B
B
C
C
66
DX
67
I
A
J
69 ADMIT
70 PATIENT
DX
REASON DX
PRINCIPAL PROCEDURE
a.
74
CODE
DATE
B
K
a
b
OTHER PROCEDURE
CODE
DATE
C
L
b.
c
D
M
71 PPS
CODE
OTHER PROCEDURE
CODE
DATE
E
N
75
72
ECI
F
O
76 ATTENDING
G
P
NPI
LAST
c.
OTHER PROCEDURE
CODE
DATE
d.
OTHER PROCEDURE
CODE
DATE
e.
OTHER PROCEDURE
CODE
DATE
77 OPERATING
81CC
a
UB-04 CMS-1450
APPROVED OMB NO.
78 OTHER
b
LAST
c
79 OTHER
d
LAST
73
QUAL
FIRST
NPI
LAST
80 REMARKS
H
Q
68
QUAL
FIRST
NPI
QUAL
FIRST
NPI
QUAL
FIRST
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
NUBC
™
National Uniform
Billing Committee
LIC9213257
| File Type | application/pdf |
| File Modified | 2016-12-19 |
| File Created | 2016-12-19 |