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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
CODE
DATE
33
OCCURRENCE
DATE
CODE
18
7
STATEMENT COVERS PERIOD
FROM
THROUGH
b
b
TYPE
OF BILL
19
20
34
OCCURRENCE
CODE
DATE
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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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
59 P. REL 60 INSURED’S UNIQUE ID
62 INSURANCE GROUP NO.
61 GROUP NAME
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
DATE
CODE
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 | 2005-04-19 |
| File Created | 2005-03-14 |