he objective of this exercise is to correctly complete a UB-04 claim form for this hospitalization.
In order to complete the claim you will need the following:
- Case Information which includes the Facility Information, Patient Information, Insurance Information, and the Patient Services.
- Fillable UB-04 Claim Form
- Download this fillable UB-04 form and use it for filling in and saving a claim form for each case.
- You can fill in this version of the form electronically, using Adobe Form Filler, as long as you have Adobe Acrobat Reader. (If you need the latest version of the free reader, you can download it from www.adobe.com.) Note: Do not try to complete the form within your browser. First, save the file to your computer. Once you have completed the form, be sure to select “save as” from the File menu and re-name the file per the instructions below. If you experience issues with this process, you may need to try another browser.