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”.
Appears in 3 contracts
Sources: Participation Agreement for Substance Use Disorder Rehabilitation Facility (Sudrf) Services, Participation Agreement for Substance Use Disorder Rehabilitation Facility (Sudrf) Services, Participation Agreement for Substance Use Disorder Rehabilitation Facility (Sudrf) Services
BILLING FORM. The SUDRF shall use the UB-92 billing form (or subsequent editions) for inpatient services, and the HCFA CMS 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”.
Appears in 3 contracts
Sources: Participation Agreement for Substance Use Disorder Rehabilitation Facility Services, Participation Agreement for Substance Use Disorder Rehabilitation Facility Services, Participation Agreement for Substance Use Disorder Rehabilitation Facility Services
BILLING FORM. The SUDRF shall use the UB-92 CMS 1450 UB-04 billing form (or subsequent editions) for inpatient services, and the HCFA CMS 1500 (08/05) 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”.
Appears in 2 contracts
Sources: Participation Agreement for Substance Use Disorder Rehabilitation Facility Services, Participation Agreement for Substance Use Disorder Rehabilitation Facility Services