WebMar 13, 2010 · A new UB-04 must be submitted each time there is a Break in Service. Box : 7 Field : Crossover indicator Description : Enter “XOVR” for Medicare Part B claims. Box : 8b Field Location : Patient Name Description : Enter the recipient name exactly as it is printed on the Medical Care ientification. DO NOT use “nicknames”. Box : 12 WebPlease refer to the UB-04 Third-Party Liability Claim Instructions to complete a UB-04 claim when the primary payer is private or other type of insurance company. Mandatory locators must be completed. Conditionally mandatory locators must be completed if applicable. Please do not write or type above locator 1 of the claim form.

UB-04 claim form and instructions - AmeriHealth

WebClaim Instructions or UB-04 Medicare Crossover Claim Instructions to on complete a UB-04 claim when Medicaid is not the primary payer. Mandatory locators must be completed. … WebForm Locator 8 a-b — Patient Name Enter the member's last name and first name, separated by a space or comma, in Form Locator 8b. Use Wisconsin's EVSto obtain the correct spelling of the member's name. If the name or spelling of the name on the ForwardHealth identification card and the EVS do not match, use the spelling from the EVS. great day houston producer

UB Form Billing – Field descriptions Medical Billing and Coding ...

WebThe UB-04 form has 81 fields and is referred to as form locators or “FL.” Each form locator has a distinctive purpose for the insurance carrier and provider so that they can communicate. To ensure a smooth process it’s … Webclaim ub 6 Family PACT – Claim Completion: UB-04 Page updated: September 2024 Figure 3: Example form for dispensing supplies, collection and handling of blood specimen, and … http://www.vtmedicaid.com/assets/forms/UB04McareAttachSummary.pdf greatdayhouston khou.com