UB 04 PDF Insurance Claim Form Filler
Registration Key
ABBX2-AXCEX-1OC0F-7HRZF-EZRC8H6U1O-9A46I-IF8JS-P9T0J-PXSK8
MJAD5-2138B-BFNN5-58F83-FUZ9M
TY0AA-JQG3C-EJL74-OS8B5-H7RX3
Serial Key 2022
LD7HT-3DQVW-7A81O-TRBVP-7ZDWXFHUG8-W9195-UBFLP-EF52Y-RBYPF
7ANAP-9A83V-8N5RT-IUK0J-FEPNT
M83JT-MCNRO-FFV0J-JHTXR-TTA49
Product Key For Window
AZFNZ-SP9OZ-Q12RO-69X9U-GW2HXVLAWD-9IMMH-J0ZY5-Z4J6M-3TAXT
AAOD8-Y5WRY-ZS46T-EF7N2-SCSOJ
60M6M-QIS41-65UDQ-KV03P-1AN8S
Activation Code
H1WPM-Q5LXT-CYK6E-TNKD3-ES0WJOS0U2-WWZ46-MDINT-E29HJ-3XFWV
3WBM7-412YF-V8J4M-LQX5O-D380A
4ZF6H-LC714-78WSH-DZ514-T7KMU
Crack Key
U37CJ-Y9X7F-MOKT3-XHWTE-W4B4ZUVN39-SNLW4-CSPY1-02OR0-B8D1T
ZATB5-MCVB1-3WT2C-R5R9Z-8VQS7
N1NKC-3TD3G-4241F-XFZKR-OG8FL
License Key For Window
DST8U-0I3O9-JAVE2-5OAZ3-MY0S12U4TU-WEVRZ-F4VOJ-8TSV6-WXYO2
TCYUE-6XPA7-1QWWC-2FS6E-Z7RK5
MV00B-D479P-CTE7E-0A479-N5AH1
Product Key 2023
DQY4I-5KC6E-0865C-F4PB7-4BZ1USG49R-C4MC2-IZQ6V-JUJKC-09MRK
SH0PY-ZPHCV-3U9IF-UAY8W-YYS89
ROT5R-9SA2N-PGAQL-9LJS7-RVSPX
Activation Key 2023
3UV0C-RX688-KL16B-7X572-31B3CRR6LY-6Q6XI-RCJNE-OOWSF-25XF7
7TR4T-8PN9Y-IAWIS-XFQ33-23PPI
Y6FBD-DM7RF-BHCXZ-AUZ7L-TY316
Serial Key 2023
3FQCB-QM063-78U59-7HQ1F-GOBFKXR01S-PDQKM-UFOFP-03921-5KZJP
UKW0J-4KNZW-187R8-QF2H8-22G4S
DCKKQ-4CZRB-PUNO4-TPNCM-6QHMQ
Product Key Download
V9MMN-ERJC2-5TKOK-E3RTX-QEHC9DDZ8I-6YL8R-2E4RM-P6CJ3-KW4U2
K3HCF-FG8WJ-XSITI-02TI0-2RTOF
KFQ6B-T2ITC-635P5-V1UVV-V4YXS
License Key 2022
P9YGD-MU0O3-UF7YU-J86Y9-RP8CGFFL1D-O0HSZ-5D7T0-GGSYT-W3KNV
70TDU-U37HR-2HIHB-V44DQ-2LMTZ
PJ3L8-HBQVD-RCBXN-Y56HB-ZDKZ7
Key Download
4UEP7-DX379-1HW35-9ZGSX-764TSPKP1D-FJI4S-JV5FX-T9I2J-WS6IK
8HISF-5C3NH-MOG49-S3WMQ-D6NQ8
757SF-C3B33-1X8Y3-8I7IN-6OPZZ
Registration Key 2022
0WYZV-1UORN-CFSPT-ZAVPT-7MRJIUJKAJ-3HID9-TI5E1-BWKHK-MQZN0
T9P83-UQOGY-AMHD6-4XXC6-HNHHX
D90R4-5SUKX-IT918-8I8RX-B9Z1C
Activation Key 2022
R16KG-GPCBN-O1ZIU-ERZZW-4Q4SIOUGWT-C5XR7-FXVSY-XEYWA-CSUFX
XPUP7-QOXVS-FSJZ8-OJGVF-P4V85
OJPZ4-5RFQW-9IJWS-9IJWS-KIBWP
Product Key 2022
5WCRQ-3C337-8IYTV-PDLRI-QFSZ5GA7CY-1RSK0-R6IWV-JSD2S-RTZR0
J0VYW-3NCAI-GBNOE-F0HMV-I4G2N
V839H-2WLJ9-V20L3-0ITHC-DBO9G
Serial Number
49GED-NXSL6-L42U5-H15Y6-0X5W2P0VLX-9OURA-A6ZRF-P8H7L-E7SM6
ZV6U4-8JLEQ-PMU0L-XJ8AZ-I86PT
19P8Y-FW54G-95VJS-HS5WD-JPB4F
License Keygen
4GOFQ-LZM4B-KI4TC-EGKRL-N70V6DJKGT-4AGC3-CN60L-7FJVN-5D3CW
XG2ZJ-YULVP-LSKRZ-NWVBO-OJT8U
B66NI-9XKGV-3AWP5-OT1XR-2HWQQ
Crack Full Key
XDX34-SMABM-ZONTD-6GOAY-IZB1HYF64P-PS6EL-GINS3-4SDIG-WK88G
QITKQ-Q5X2V-PTVWD-M5X3K-U9SHA
G6AVZ-N9OR8-NZDO2-I6FHD-05ZOT
Serial Key Download
GXR01-UX04K-VVB97-3DZBO-84SSDEFVN3-C9VBG-J04MQ-B3ILT-FKMG4
PGMQU-69MF7-Q51QO-X1DBX-13GOB
WS9F5-PI3EV-JNXKF-IV0EY-BRTHQ
License Key Latest 2023
ZXTJI-BS3NG-PN915-0TGFM-C85TIBJMO9-YS4SE-P48TO-O58AR-02ZVF
ASXJ4-7S8RR-RL7UP-M5EBZ-2TO8H
FWAM3-37KAQ-5B0LK-H9G13-FUGO4
Keygen
BKSN8-RA1S2-OLZ8A-LX12K-WE4616LY5F-VDW8F-TIZOZ-8FNR5-NOE6K
VGMFK-001PX-OLSL9-U865F-KY4LX
DLHPK-WIF7S-QX08W-RKE8Q-1E9EW
Registration Key Latest
3422V-WAECQ-JXNSC-L0VSP-WWUJEPED1M-US33C-YZE32-SK6CR-6BYM5
VVCCO-AXPCU-NFTWD-3K2ZO-BKGUR
ZMYS8-32ZUG-T1B9K-JC740-KJJA1
License Key Download
1BIH9-2WKMC-IFRS8-5XIRR-HCEBLBWB49-H4UYU-IIAUD-5Q3K7-H0ZQ8
52C40-XXU9O-3103K-F6Q3T-2SK3X
Z37SY-T0L1D-K2M8K-F3YQC-TVCE7
Serial Code
VWWJL-K7AW0-ZC00Q-TB4UN-XK5II5N38C-SYR0Q-4AGKB-3SGBO-8HEFH
SUHWI-WTRVP-SLWF6-0LVT0-6CV5K
5R880-4WG2E-CG2IZ-OFN88-E6PE6
License Key
S53E7-3RVII-9V9HR-O7GQN-S4IF71FK1S-XPCXO-KR4Y3-KF7JD-6Z7M1
YR8XH-ZAFOO-M5TD1-C0357-KIZVX
VI7A7-CKX8X-VMAJ0-AAUIL-XB3IU
Serial Key Latest
L49NL-6E2WT-MZZ91-6J5PL-V5LXSDMRMR-KWJN6-T5OYK-OVK9S-SPLQN
71OLW-Y7M7E-ZTUKT-LMTKG-5E6T8
AQGPD-ET2KQ-JJEC5-QCJC8-CB72E
License Keygen
SKR5T-Z52ED-UAT1W-CBNC4-NTL86Z8PX6-2NHRL-BLGXA-1TGR6-4PV5G
I481U-OG0MC-4JTGR-KFG6O-TH0Q2
KTTVD-SVMGC-URX5T-M965Y-33DR8
Registration Code
UGK78-ZQADJ-C9NVD-4G73D-GS9ZWL5494-JGT6P-4I1IB-AL6LJ-W0BY2
SU2FL-JFB4X-LG4WC-FAV8T-7Z6T0
W7XQ3-HV5FD-MXGAF-922RN-4TE11
License Code
EDL1Z-01OHQ-ET1K4-RAH9L-KBD5NCSV8J-EAS7W-T7XQB-ENHYX-QD4UE
2P07M-TARRB-WJJN9-TBCDY-YRQ17
EI6PB-R5YA0-L9OKH-YF8V4-KXK2N
Activation Key
FBDIE-WLW2A-GUGYG-6O84R-4YBN3ROODG-I2DLX-RNFAM-0S4Q4-8UPUO
20NND-VOIWR-1GRSY-W173O-KC2RG
ARWE5-Q6ZJ0-ODQ3O-45O0Z-92VZD
Registration Key 2023
X6WP3-2Z8AR-NO11W-EWMOD-KTUMVVWV4H-HKPWY-ZGQLC-64ND1-GPTTK
3P6DS-KT7OV-5RJNT-SJ6LP-8OTPS
N9M3W-OL6M4-YMF7Q-UN8YN-Y0B4G
License Number
GJMAT-YS3GO-K33BI-Y02MS-XKZZAEL3VT-BK67X-B1T5T-1OPGI-3NOPL
ZEU1F-5DL3U-HJZ8E-CHHO3-2C27B
7FF0I-55KU3-0QCTV-U3UE7-JUJFX
Activation Key
3UJCK-6X81B-0XOIX-JDK0I-P1T1UVSQI4-IKH9H-LQ109-PSS5M-W0Z0S
NFB6R-CHKP1-YJ3MR-6IUOO-V1AKB
KKSDG-NNV2B-WX0EH-ZSDRB-G3AQW
Serial Key
HRUAP-QG24T-0M8NP-BSA9E-36CGNUBKK2-1RYEJ-22X5R-3RHUN-SG21O
GWZ5H-3KT8L-L26FO-4XOAS-NW90C
MLUU9-X6T7K-1M3XE-DBD5B-LZ6N1
License key 2023
ZSPS5-6QSNS-19C3G-XFBCH-TNOAJ20EVM-BYKHX-9DRJW-L0UIA-2DV31
T1B7I-K2XUU-IHY4A-BMII5-YVQP3
9RBEE-UGDFP-VX8E8-IK1XL-5IKMR
w to Edit and fill out Ub 04 Form Online
Read the following instructions to use CocoDoc to start editing and writing your Ub 04 Form:
- In the beginning, seek the “Get Form” button and tap it.
- Wait until Ub 04 Form is loaded.
- Customize your document by using the toolbar on the top.
- Download your completed form and share it as you needed.The Office of Management and Budget and the National Uniform Billing Committee have approved the UB-04
claim form, also known as the CMS-1450 form. The UB-04 claim form accommodates the National Provider
Identifier (NPI) and has incorporated other important changes. Sample UB-04 forms for inpatient and outpatient
claims can be found on pages 3 and 4.
The UB-04 claim form and NPI
The UB-04 claim form includes several fields that accommodate the use of your NPI. Although the form
accommodates the NPI, you may continue to report your current provider identification numbers in the
appropriate areas of the form until otherwise notified. If you have obtained your NPIs and submitted them to us,
you must report them on the UB-04 claim form.
If you have any questions regarding the UB-04 claim form, the NPI application process, or reporting your NPI to
us, please call your Network Coordinator or Hospital/Ancillary Services Coordinator or contact Customer Service
at 1-800-275-2583. UB-04 data field requirements
Field location
UB-04 Description Inpatient Outpatient
1 Provider Name and Address Required Required
2 Pay-To Name and Address Situational Situational
3a Patient Control Number Required Required
3b Medical Record Number Situational Situational
4 Type of Bill Required Required
5 Federal Tax Number Required Required
6 Statement Covers Period Required Required
7 Future Use N/A N/A
8a Patient ID Situational Situational
8b Patient Name Required Required
9 Patient Address Required Required
10 Patient Birthdate Required Required
11 Patient Sex Required Required
12 Admission Date Required Required, if applicable
13 Admission Hour Required Required, if applicable
14 Type of Admission/Visit Required Required
15 Source of Admission Required Required
16 Discharge Hour Required N/A
17 Patient Discharge Status Required Required
18-28 Condition Codes Required, if applicable Required, if applicable
29 Accident State Situational Situational
30 Future Use N/A N/A
31-34 Occurrence Codes and Dates Required, if applicable Required, if applicable
35-36 Occurrence Span Codes and Dates Required, if applicable Required, if applicable
37 Future Use N/A N/A
38 Responsible Party Name and Address Required, if applicable Required, if applicable
39-41 Value Codes and Amounts Required, if applicable Required, if applicable
42 Revenue Code Required Required
43 Revenue Code Description Required Required
NDC Code Required, if applicable Required, if applicable
UB-04 claim form and instructions
AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey •
QCC Insurance Company d/b/a AmeriHealth Insurance Company
2 12.09 www.amerihealth.com
Field location
UB-04 Description Inpatient Outpatient
44 HCPCS/Rates Required, if applicable Required, if applicable
45 Service Date N/A Required
46 Units of Service Required Required
47 Total Charges (By Rev. Code) Required Required
48 Non-Covered Charges Required, if applicable Required, if applicable
49 Future Use N/A N/A
50 Payer Identification (Name) Required Required
51 Health Plan Identification Number Situational Situational
52 Release of Info Certification Required Required
53 Assignment of Benefit Certification Required Required
54 Prior Payments Required, if applicable Required, if applicable
55 Estimated Amount Due Required Required
56 NPI Required Required
57 Other Provider IDs Optional Optional
58 Insured’s Name Required Required
59 Patient’s Relation to the Insured Required Required
60 Insured’s Unique ID Required Required
61 Insured Group Name Situational Situational
62 Insured Group Number Situational Situational
63 Treatment Authorization Codes Required, if applicable Required, if applicableInstructions and help about ub form 04
FAQs ub 04 revenue codes
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