Manual Claim UB04
1
2
3
4
5
8
10
6
9
7
RESERVED
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
27
29
30
RESERVED
31
32
33
34
35
36
Reserved
37
38
39
40
41
42 REV. CD |
43 DESCRIPTION |
44 HCPCS / R ATE / HIPPS CODE |
45 SE RV. DATE |
46 SE RV. UNITS |
47 TOTAL CHARGES |
48 NON-COVERED CHARGES |
49 |
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| Page ------- of ------ | Creation Date | TOTALS | 550.00 | 0.00 | |||
50
53
51
54
52
55
56
59
60
57
61
58
62
63
66
64
67
Reserved
65
68
Reserved
69
70
71
72
73
Reserved
74
75
Reserved
76
77
78
79
80
81