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837 Institutional/UB-04 Claim Form. UB-04 Desk Reference for Hospitals. ThesevaluesarevalidforpaperclaimsubmissionontheUB-04ClaimFormonly. Type of Bill
CMS-1450/UB-04 Quick Reference Billing Guide. 1487IL0816-B. Department. Function. Contact Number. Independent Living. Systems (ILS) Provider Help. Line.
reference guide and tool for the UB-04. This section will give a detailed view of “box by box” view to help guide through the UB-04 claim form. Box 1 – Billing
Premera Reference Manual. Premera Blue Cross. 023695 (02-2012). UB-04 Billing. Chapter 12 Page 1. 12 UB-04 Billing. Description. This chapter contains
data elements for inclusion to the UB-04 Manual and the layout of the UB-04 form. segment and element, the user should verify the corresponding reference.
30 Jan 2017 The purpose of this document is to provide a block-by-block reference guide to assist the following provider types in successfully completing the
Disclaimer for manual changes only: The revision date and transmittal number apply 25/75/General Instructions for Completion of Form CMS-1450 (UB-04). R.
Tips for Completing the UB04 (CMS-1450) Claim Form. Page 8 of 17. UB04 (CMS-1450) REFERENCE MATERIAL1. Type of Bill Codes (Field 4). This is a
Reference Billing Guide .. wwwwpc-edi.com/reference. Therapy Cap NOTE: Submitting a copy of the UB04 is not an acceptable appeal request.
Institutional Claim (UB-04) Field Descriptions. Following electronic descriptions provided here are intended only as a guide for . Original Reference Number).
     

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