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Elizabeth M. Whitehorn, Director

Provider Notice issued 12/30/08

​ UB-04 Paper Billing Requirements for HFS Adjudication of Inpatient, Outpatient, and Renal Dialysis Claims
 

​To ​Participating Hospitals:  Chief Executive Officers, Chief Financial Officers, Patient Accounts Managers, and Health Information Management Directors; Renal Dialysis Facilities; and Ambulatory Surgical Treatment Centers (ASTCs)
​Date: ​December 30, 2008
​Re: ​ UB-04 Paper Billing Requirements for HFS Adjudication of Inpatient, Outpatient, and Renal Dialysis Claims

The department has prepared instructions for paper UB-04 inpatient, outpatient ASTC, outpatient hospital (general, rehabilitation, and psychiatric), and renal dialysis claims, to assist providers in completing their institutional claim forms.  The information communicated in the December 21, 2006, and March 15, 2008, provider notices has been incorporated into these instructions.

Providers should use these billing guidelines in conjunction with the UB-04 Data Specifications Manual. To become a UB-04 Subscriber, refer to the following Web site at: http://www.nubc.org/become.html

The billing guidelines are posted along with this notice on the Department's Web site at: <http://www.illinois.gov/hfs/MedicalProviders/notices/Pages/default.aspx> under the ASTC, Hospital, and Renal Dialysis labels. Any questions regarding this notice should be directed to your facility’s medical assistance consultant in the Bureau of Comprehensive Health Services at 1-877-782-5565.

 

Theresa A. Eagleson, Administrator

Division of Medical Programs

 

UB-04 Requirements for HFS Adjudication (pdf)