Minimum Requirements for Claims Submission

For HMSA's claims processing system to register and track a facility claim, the following elements must be included on the UB-04:

• Patient's valid HMSA member ID number
• Patient's legal name
• Procedure code/Revenue code
• Charge
• Valid HMSA provider number
• Signature or initials of provider or authorized agent

Note: Including all the elements listed above does not mean that a claim will automatically be processed for payment; it simply allows HMSA's system to register the claim. Additional information, as described in the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual is needed to process the claim for payment. For HMSA-specific instructions, the UB-04 - HMSA Data Requirements by Field [PDF] is an interactive version of the UB-04 form.

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