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ADMISSION CONDITION CODESDATE

OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPANCODE DATE CODE CODE CODE DATE CODE THROUGH

VALUE CODES VALUE CODES VALUE CODESCODE AMOUNT CODE AMOUNT CODE AMOUNT

TOTALS

PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPICODE DATE CODE DATE CODE DATE

FIRST

c. d. e. OTHER PROCEDURE NPICODE DATE DATE

FIRST

NPI

b LAST FIRST

c NPI

d LAST FIRST

UB-04 CMS-1450

10 BIRTHDATE 11 SEX 12 13 HR 14 TYPE 15 SRC

DATE

16 DHR 18 19 20

FROM

21 22 23

CODE FROMDATE

OTHER

PRV ID

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

b

.INFO BEN.

CODEOTHER PROCEDURE

THROUGH

29 ACDT 30

3231 33 34 35 37

38 39 40 41

42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

52 REL51 HEALTH PLAN ID

53 ASG.54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI

57

58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

66 67 68

69 ADMIT 70 PATIENT 72 73

74 75 76 ATTENDING

80 REMARKS

OTHER PROCEDURE

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77 OPERATING

78 OTHER

79 OTHER

81CC

CREATION DATE

44 HCPCS / RATE / HIPPS CODE

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63 TREATMENT AUTHORIZATION CODES

9 PATIENT ADDRESS

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0.00 0.00

298370064

1 2 4 TYPEOF BILL

FROM THROUGH5 FED. TAX NO.

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VALUE CODES VALUE CODES VALUE CODESCODE AMOUNT CODE AMOUNT CODE AMOUNT

PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPICODE DATE CODE DATE CODE DATE

FIRST

c. d. e. OTHER PROCEDURE NPICODE DATE DATE

FIRST

NPI

b LAST FIRST

c NPI

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UB-04 CMS-1450

7

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DATE

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53 ASG.54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI

57

58 INSURED’S NAME 59 P.REL 60 INSURANCE GROUP NO.

65 EMPLOYER NAME

66 67 68

69 ADMIT 70 PATIENT 72 73

74 75 76 ATTENDING

80 REMARKS

OTHER PROCEDURE

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SPAN

25 26 2827

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24 64 DOCUMENT CONTROL NUMBER

298370064

 

 

Process for Corrected Claims or Voided Claims

Corrected and/or voided claims are subject to timely claims submission (i.e., timely filing) guidelines. 

To submit a Corrected or Voided Claim electronically (EDI):        

 

• For Institutional and Professional claims, providers must include the original WellCare claim number in Loop 2300 segment REF*F8 with the claim’s Frequency Code (CLM05­3) of 7 (Replacement of prior claim) or 8 (Void/cancel of prior claim). Please refer to the 5010 Implementation Guides or WellCare’s Companion Guides for complete details.

To submit a Corrected or Voided Claim on paper:

TOTALSCREATION DATE 0.00

     

• For Institutional claims, the provider must include the original WellCare claim number and bill frequency code per industry standards.

Example:

Box 4 – Type of Bill: the third character represents the “Frequency Code”

Box 64 – Place the Claim number of the Prior Claim in Box 64

OTHER

PRV ID

INSURED’S UNIQUE ID 61 GROUP NAME 62

3a PAT. CNTL #

4 TYPE OF BILL

b. MED. REC. # 117 5 FED. TAX NO. 6

FROM STATEMENT

THROUGH COVERS PERIOD 7

Continued on next page

1a. INSURED’S I.D. NUMBER (For Program in Item 1)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH

b. EMPLOYER’S NAME OR SCHOOL NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize

services described below.

SEX

F

HEALTH INSURANCE CLAIM FORM

OTHER

(ID)

1. MEDICARE MEDICAID TRICARE CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary

below.

SIGNED DATE

ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)

MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

FromMM DD YY

ToMM DD YY

1

2

3

4

5

625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

(For govt. claims, see back )

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY

$ CHARGES

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$

$ $

PICA PICA

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

5. PATIENT’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH

c. EMPLOYER’S NAME OR SCHOOL NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

( )

If yes, return to and complete item 9 a-d.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB? $ CHARGES

23. PRIOR AUTHORIZATION NUMBER

MM DD YY

CA

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YES NO

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1. 3.

2. 4.

DATE(S) OF SERVICEPLACE OFSERVICE

D. PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIERDIAGNOSIS

POINTER

FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG

Single Married Other

3. PATIENT’S BIRTH DATE

6. PATIENT RELATIONSHIP TO INSURED

8. PATIENT STATUS

a. EMPLOYMENT? (Current or Previous)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

10d. RESERVED FOR LOCAL USE

Student

Self Spouse Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN)

( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. E.

PROVIDER ID. #

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

EMGRENDERING

32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

c. INSURANCE PLAN NAME OR PROGRAM NAME

Full-TimeEmployed

Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

G.EPSDTFamilyPlan

ID.QUAL.

CHAMPUS

( )

1500

APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)PLEASE PRINT OR TYPE

10. IS PATIENT’S CONDITION RELATED TO:

Student

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For Professional claims, the provider must include the original WellCare claim number and bill frequency code per industry standards. When submitting a Corrected or Voided claim, enter the appropriate bill frequency code left justified in the left­hand side of Box 22.   

Example: 

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO.

7 OR 8 1234567890A33456

Please Note: Any missing, incomplete or invalid information in any field may cause the claim to be rejected. If you handwrite, stamp, or type “Corrected Claim” on the claim form without entering the appropriate Frequency Code “7” or “8” along with the original claim number as indicated above, the claim will be considered a first­time claim submission.

The Correction Process involves two transactions: 1. Reversal of the original claim ­ The original claim will be reversed and noted with an adjustment reason code RV059.

“Payment Reversal – Payment lost/voided/missed.” This process will deduct the prior payment. The Payment Reversal for this process may generate a negative amount, which may be offset from future payments rather than on the EOP that is sent out for the newly submitted corrected claim.

2. Adjudication of corrected claim ­ The corrected claim will be processed with the newly submitted information and noted with an adjustment code CL025 “Adjusted per corrected bill.” This process will pay out the newly calculated amount on a new claim with a new claim number.

The Void Process involves the following transaction: Reversal of the original claim ­ The original claim will be reversed and the subsequent claim submitted with an 8 (Void/cancel of prior claim) will be processed as a zero payment and noted with an adjustment reason code RV059 “Payment Reversal – Payment lost/voided/missed.” This process will deduct the prior payment or zero net amount if applicable.

NA022533_PRO_FLY_ENG State Approved 06282013  ©WellCare 2013  NA_05_13

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