BILLING FORM Clause Samples
The Billing Form clause defines the specific format and structure in which invoices or billing statements must be submitted under an agreement. It typically outlines the required information, such as itemized charges, dates of service, and any supporting documentation that must accompany each bill. By standardizing the billing process, this clause ensures consistency, reduces errors, and facilitates timely payment by making it clear what is expected from both parties.
BILLING FORM. The SUDRF shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form (or subsequent editions) for inpatient services, and the CMS 1500 Claim Form for outpatient services. The SUDRF shall identify SUDRF care on the billing form in the remarks block by stating “SUDRF care”.
BILLING FORM. The IOP shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form and the CMS 1500 Claim Form for outpatient services (or subsequent editions). IOPs shall identify IOP care on the billing form in the remarks block by stating “IOP care.”
BILLING FORM. The PHP shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form and the CMS 1500 Claim Form for outpatient services (or subsequent editions). PHPs shall identify PHP care on the billing form in the remarks block by stating “PHP care”.
BILLING FORM. The OTP shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form and the CMS 1500 Claim Form for outpatient services (or subsequent editions). OTPs shall identify opioid treatment care on the billing form in the remarks block by stating “OTP care.”
BILLING FORM. (a) The hospice program shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form (or subsequent editions.) Hospice care shall be identified in item 4 of this form.
(b) The CMS 1450 UB-04 billing form (or subsequent editions) will also be used as an admission notice. This notice will be used to notify the contractor of the initiation, change or revocation of an election.
BILLING FORM. (a) The RTC shall use the UB-92 billing form (or subsequent editions).
(b) RTCs shall identify RTC care on the billing form in the remarks block by stating “RTC care”.
(c) RTCs shall identify on the billing form those days that patient was absent from the facility. This includes therapeutic absences as well as unplanned absences.
(d) Charges for geographically distant family therapy must be billed in the RTC patient’s name and be authorized by TMA or designee.
BILLING FORM. The PHP shall use the UB-92 billing form (or subsequent editions). PHPs shall identify PHP care on the billing form in the remarks block by stating “PHP care”.
BILLING FORM. (a) The RTC shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form (or most current subsequent editions).
(b) RTCs shall identify RTC care on the billing form in the remarks block by stating “RTC care”.
(c) RTCs shall identify on the billing form those days that patient was absent from the facility. This includes therapeutic absences as well as unplanned absences.
(d) Charges for geographically distant family therapy must be billed in the RTC patient’s name and be authorized by DHA or designee.
BILLING FORM. The SUDRF shall use the UB-92 billing form (or subsequent editions) for inpatient services, and the HCFA 1500 claim form for partial hospitalization or outpatient services. The SUDRF shall identify SUDRF care on the billing form in the remarks block by stating “SUDRF care”.
BILLING FORM. (a) The hospice program shall use the UB-92 billing form (or subsequent editions.) Hospice care shall be identified in item 4 of this form.
(b) The UB-92 billing form (or subsequent editions) will also be used as an admission notice. This notice will be used to notify the contractor of the initiation, change or revocation of an election.