Ub 04 example: free download. On-line document store on 5y1.org

Commonwealth of Massachusetts
Example: Billing an NDC drug. Example: Billing a compound drug . 43 (Line 23) Page__ of __ MassHealth accepts only single-page UB-04 claims. This should always be Page 1 of 1. 44 (Lines 1-22) HCPCS/ Rates/HIPPS Code If required, enter the HCPCS code and modifier applicable to ancillary service and outpatient bills. ... Complete the UB-04 Paper ...
example ub 04 claim form

[DOC File]Form Locator Number
https://info.5y1.org/ub-04-example_1_f0b475.html
5 Provider’s Federal Tax Identification Number 6 Date(s) of Service (Enter MMDDYY, example 010106) 7 Leave Blank 8a Patient ID (Required if different than the subscriber/insured ID in Form Locator 60) 8b Patient’s Name (last name, first name, middle initial) 9a Patient’s Address-Street 9b Patient’s Address-City 9c Patient’s Address ...
ub04 sample completed

[DOC File]UB04 Billing Instructions Guide - Maine
https://info.5y1.org/ub-04-example_1_858399.html
Jun 08, 2020 · The UB-04 claim is a billing form maintained by the National Uniform Billing Committee (NUBC). Each payer, including MaineCare, has different requirements for completing specific parts of the claim form. ... Example: If a claim is submitted for July and later a rate letter is received to increase the rate effective in July: Enter a 7 as the ...
sample ub 04 form filled out

[DOC File]UB-04 Submission and Timeliness Instructions (ub sub)
https://info.5y1.org/ub-04-example_1_7d3010.html
Title: UB-04 Submission and Timeliness Instructions (ub sub) Author: Ronald Yaw Description: Pgs. 1-5 (08.2000) RP pgs. 3-4 (03.06.01) RP pgs. 3-4 (10.04.02) RP pgs. all 1-5 (09.05.03) LB pgs. all 1-6 (06.09.05) LB pgs. 1-2 (12.07.05) LB pgs. 1-2 (01.10.06) LB pgs. 3-6 (05.05.06) LB pgs. 1-5, 6 new (05.10.07) May 2007 NPI LB pgs. 1-2 (05.09.07) LB pgs. all (10.03.07) no content change, only ...
ub billing form sample

Ub 04 example