How to Fill Out a Ub92 Claim Form

UB-92 claim forms are used when billing hospital inpatient and outpatient visits to Medicare, Blue Cross, Medicaid, TriCare and other commercial insurance companies. It is a uniform billing form that provides the codes for the procedures performed as well as the conditions and diagnoses present. The insurance company uses this information and determines the payment due for the procedures performed. The UB-92 is rarely used, having been replaced by the UB-04 claim form.

Things You'll Need

• Medical codes
• Insurance information

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Instructions

• 1

  Enter the provider's, or facility's, name and address in Box 1. Format the information with the provider's full name on line one, the street address on line two, and the city, state and zip code on line three.

• 2

  Move to Box 3 and enter the patient's control number or account number. Enter the numbers from left to right.

• 3

  Place the provider's federal tax identification number in Box 5. Box 6 is reserved for the dates of coverage. Boxes 7 thorough 11 are not required unless specified by the insurance company.

• 4

  Enter the patient's name in Box 12 along with his address in Box 13. The patient's birthday is required in Box 14. Box 15 requires an "M" for male or "F" for female.

• 5

  Provide the admission information in Boxes 17 through 22. The medical records number for the patient is required in Box 23. Condition codes go in Boxes 24 through 31.

• 6

  Complete Boxes 32 through 37 by providing any applicable occurrence codes that affect the way the claim should be processed by the payer. Boxes 39 through 41 are reserved for value codes. These specialized codes represent data elements required by the payer organization to process the claim, such the hour of accident according to NADHO.

• 7

  Enter the procedure codes and charges in Boxes 42 through 49. Use the Current Procedural Terminology (CPT) manual for the acceptable codes.

• 8

  Provide the payer's name in Box 50 and the provider's number in Box 51. Mark a "Y' in Box 53 to accept assignment. This allows the insurance to pay the provider directly.

• 9

  Enter previous payments and the amount due in Boxes 54 and 55, respectively. Boxes 58 though 66 require information from the patient regarding insurance. Supply the requested information in each box.

• 10

  Place the primary diagnosis code in Box 67. Enter additional codes in the boxes provided. Use Box 79 through 81 and report the procedures performed. Supply the attending physician's information in Box 82. Add another physician if necessary in Box 83.