UB-04 CLAIM FORM INSTRUCTIONS
Source of Admission Enter one of the following source of admission codes: 1 = Physician Referral . 2 = Clinic Referral . 3 = HMO Referral . ... 81cc Code-Code Field Enter B3 in the qualifier if fields 76-79 contain an NPI. Enter the corresponding provider taxonomy of provider NPI’s entered in locations 76a – 81CCa . ................
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