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 RTC shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form (or most current subsequent editions).
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. 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 RTC shall use the UB-92 billing form (or subsequent editions).
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.
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.
