Filling out a UB-04 form for Aflac claims can be a daunting task, especially for those who are new to the process. The UB-04 form, also known as the Uniform Billing Form, is a standardized form used by healthcare providers to bill insurance companies for services rendered. Aflac, a leading supplemental insurance provider, requires this form to process claims efficiently. In this article, we will guide you through the process of filling out a UB-04 form for Aflac claims, highlighting five essential steps to ensure accuracy and completeness.
Understanding the UB-04 Form
Before diving into the filling-out process, it's essential to understand the UB-04 form's structure and requirements. The form consists of 81 fields, each serving a specific purpose. The form is divided into several sections, including patient information, billing information, and service details.
Step 1: Patient Information (Fields 1-13)
The first section of the UB-04 form requires patient information. This section is crucial, as it helps Aflac identify the claimant and process the claim accurately.
To complete this section:
- Enter the patient's name, date of birth, and address in fields 1-4.
- Provide the patient's policy number, group number, and insurance type in fields 5-7.
- List the patient's phone number and email address in fields 8-9.
- Specify the patient's relationship to the policyholder in field 10.
- Enter the patient's employer and job title in fields 11-12.
- Indicate the patient's marital status and occupation in field 13.
Step 2: Billing Information (Fields 14-25)
The next section requires billing information, which is vital for Aflac to process the claim correctly.
To complete this section:
- Enter the billing provider's name, address, and tax ID number in fields 14-16.
- Provide the billing provider's phone number, fax number, and email address in fields 17-19.
- Specify the billing provider's NPI (National Provider Identifier) number in field 20.
- Indicate the billing provider's specialty and taxonomy code in fields 21-22.
- Enter the billing provider's ZIP code and county code in fields 23-24.
- Specify the billing provider's billing address in field 25.
Step 3: Service Details (Fields 26-43)
This section requires details about the services provided to the patient.
To complete this section:
- Enter the date of service, procedure code, and modifier in fields 26-28.
- Specify the charge amount, unit count, and total charge in fields 29-31.
- Indicate the service provider's NPI number and taxonomy code in fields 32-33.
- Enter the service facility's name, address, and ZIP code in fields 34-36.
- Provide the service facility's NPI number and taxonomy code in fields 37-38.
- Specify the service facility's billing address in field 39.
- Enter the referring physician's name and NPI number in fields 40-41.
- Indicate the primary diagnosis code and secondary diagnosis code in fields 42-43.
Step 4: Additional Information (Fields 44-60)
This section requires additional information to support the claim.
To complete this section:
- Enter the primary insurance coverage and secondary insurance coverage in fields 44-45.
- Specify the patient's employment status and workers' compensation information in fields 46-47.
- Indicate the patient's military status and TRICARE information in fields 48-49.
- Enter the patient's Social Security number and Medicare number in fields 50-51.
- Provide the patient's Medicaid number and state-specific information in fields 52-53.
- Specify the patient's other insurance coverage and related information in fields 54-60.
Step 5: Certification and Signature (Fields 61-81)
The final section requires certification and signature from the billing provider.
To complete this section:
- Enter the billing provider's signature, title, and date in fields 61-63.
- Specify the billing provider's certification statement in field 64.
- Indicate the billing provider's compliance with HIPAA regulations in field 65.
- Enter the billing provider's contact information in fields 66-67.
- Provide the billing provider's NPI number and taxonomy code in fields 68-69.
- Specify the billing provider's billing address in field 70.
- Enter the billing provider's fax number and email address in fields 71-72.
- Indicate the billing provider's specialty and taxonomy code in fields 73-74.
- Enter the billing provider's ZIP code and county code in fields 75-76.
- Specify the billing provider's billing address in field 77.
- Enter the billing provider's NPI number and taxonomy code in fields 78-79.
- Indicate the billing provider's certification statement in field 80.
- Enter the billing provider's signature, title, and date in field 81.
By following these five essential steps, you can ensure accuracy and completeness when filling out a UB-04 form for Aflac claims. Remember to double-check your entries and provide all required information to avoid delays or denials.
What is the purpose of the UB-04 form?
+The UB-04 form, also known as the Uniform Billing Form, is a standardized form used by healthcare providers to bill insurance companies for services rendered.
How do I fill out the patient information section?
+To fill out the patient information section, enter the patient's name, date of birth, and address in fields 1-4. Provide the patient's policy number, group number, and insurance type in fields 5-7. List the patient's phone number and email address in fields 8-9. Specify the patient's relationship to the policyholder in field 10. Enter the patient's employer and job title in fields 11-12. Indicate the patient's marital status and occupation in field 13.
What information is required in the billing information section?
+The billing information section requires the billing provider's name, address, and tax ID number in fields 14-16. Provide the billing provider's phone number, fax number, and email address in fields 17-19. Specify the billing provider's NPI (National Provider Identifier) number in field 20. Indicate the billing provider's specialty and taxonomy code in fields 21-22. Enter the billing provider's ZIP code and county code in fields 23-24. Specify the billing provider's billing address in field 25.
By following these steps and guidelines, you can ensure that your UB-04 form is filled out accurately and completely, helping to expedite the claims process and reduce the risk of delays or denials.