A Guide for Completing the UB-04 Form

A Guide for Completing the

UB-04 Form

The Uniform Bill (UB-04) is the standardized billing form for institutional services. Scott & White Health Plan offers this guide to help you complete the UB04 form for your patients with the Scott & White Health Plan coverage. Thank you for helping us to process your claims efficiently and accurately.

MAIL CLAIMS TO:

Scott & White Health Plan P.O. Box 21800 Eagan, MN 55121-0800

R

C

SW

R

R

R

C CC R C C

C

C

C

C

R C

C

NR

C

R

C

R

R

NR

C C

R

NR

NR NR

C

R

R

C

C

R

R

SW

NR

SAMPLE

R

NR

C

R

NR

R

C

C

NR

C

C

C

C

C

C

C

C

C

R R

NR

C

NR

R

SW

NR

C

NR

SW

NR

C

NR

C

C

NR

NR

NR

R

R

C

C

C

C

C

C

KEY

R TDI Requirement C Conditional SW SWHP Requirement NR Not Required

R

C

C

R C R

C NR

NR

C

C

R R

NR

R SW

R

R R

C

C

NR NR

C R

R

C C

R

R C

R

SW

NR

C

R TDI Requirement

KEY C Conditional SW SWHP Requirement NR Not Required

R

NR NR

C

NR

NR R R C

R NR

SW

NR

R C

R

NR

SW

NR

C C

R

C

C C

NR NR

C

C C

NR

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download