Txhawm rau ua raws li Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) cov cai, daim ntawv thov tus neeg mob yuav tsum tsuas yog sau nqi rau cov kev pabcuam hnub tim hauv daim ntawv tshaj tawm. Cov lej sau hnub ua ntej lossis tom qab hnub nqe lus tau them nqi tsis raug.
Cov lej uas yuav tsum tau poob rau lossis tsis pub dhau hnub nqe lus suav nrog: qhov tshwm sim, txheej txheem txheej txheem thiab lwm yam txheej txheem. Yog tias hnub tim ntawm ib qho code sau nqi tsis poob ntawm lub sij hawm daim ntawv teev hnub, qhov kev thov yuav ua tsis raug. Saib daim ntawv theej uas raug UB-04 daim ntawv thov ua piv txwv hauv qab no.
UB-04 Hardcopy, Field 6: Nqe Lus Nug Txog Lub Sijhawm
Nkag mus rau qhov pib thiab xaus hnub ua haujlwm ntawm tag nrho lub sijhawm uas tau them rau hauv daim ntawv thov hauv MMDDYY hom ntawv. Rau cov kev pabcuam muab rau ib hnub, nkag mus rau hnub ua haujlwm raws li hnub "los ntawm" thiab "txog" hnub. Lwm cov lis dej num xa tuaj rau ntawm daim ntawv thov yuav tsum poob rau lossis nyob rau hauv nqe lus suav nrog hnub tim.
Kev xa hluav taws xob: 837I Loop 2300, Ntu DTP nrog kev tsim nyog 434.
UB-04 Hardcopy, Fields 12-13: Nkag / Pib Hnub Kho Mob thiab Sijhawm Nkag Nkag
Nkag mus rau hnub nkag mus rau cov kev pabcuam neeg mob. Nkag mus rau hauv MMDDYY hom. Hnub uas tus neeg mob raug lees paub raws li tus neeg mob nyob hauv tsev raug suav tias yog thawj hnub tus neeg mob nyob hauv tsev; qhov no yuav tsum tsis txhob hloov.
Nkag mus rau lub sijhawm lees paub raws li hauv qab no: Tshem tawm cov feeb thiab hloov lub sijhawm nkag / tawm mus rau 24-teev (00 - 23) hom (piv txwv li, 3 teev = 15)
Kev xa hluav taws xob: 837I Loop 2300, Ntu DTP nrog kev tsim nyog 435.
UB-04 Hardcopy, Fields 31-34: Codes tshwm sim thiab hnub tim
Nkag mus rau qhov chaws thiab cov hnub uas cuam tshuam nrog ceeb toom txog qhov xwm txheej tseem ceeb ntsig txog qhov kev thov uas yuav cuam tshuam rau kev them nyiaj.
UB-04 Hardcopy, Fields 35-36: tshwm sim Span Codes thiab hnub tim
Nkag mus rau tus lej thiab cov hnub muaj feem cuam tshuam uas txheeb xyuas qhov xwm txheej cuam tshuam txog kev them nyiaj ntawm daim ntawv thov.
UB-04 Hardcopy, Field 74: Principal Procedure Code thiab Hnub tim
ICD-10-CM code rau cov txheej txheem tseem ceeb thiab hnub ua tiav.
UB-04 Hardcopy, Fields 74a – 74e: Lwm Cov Txheej Txheem Txheej Txheem thiab Hnub Tim
Nkag mus rau ICD-10-CM cov txheej txheem cov lej thiab hnub rau txog 5 cov txheej txheem ntxiv.
Yog tias koj muaj lus nug lossis xav paub ntxiv, thov hu rau Alliance Claims department ntawm (800) 700-3874, ext. ib 5503.