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your healthcare provider to assign benefits to the provider. If you choose to assign benefits, attach a signed and written request. Email form to groupclaimfiling@aflac.com or fax to 1.866.849.2970.
What you need to file a claim. Patient’s name and date of birth. Patient’s relationship to policyholder. Date of injury or when symptoms first occurred. Physician’s name, address and phone/fax number. Definitions & acronyms. Emergency room (ER). Itemized hospital bill (IHB). UB04 (itemized hospital bill). HCFA 1500 (non-hospital bill).
Obtaining a UB 04 form from a hospital is essential for accurate and timely medical billing. By following the steps outlined in this guide and providing the necessary information, you can streamline your billing process and ensure prompt reimbursement from insurance companies.
UB04 (itemized hospital bill). Definitions & acronyms ER report or operative report. (Please obtain the supporting documents for the corresponding benefit.) (Please include at least three pieces of identifying information.) Hospital confinement - IHB or UB04. Major diagnostic imaging - Scan/imaging report. Ambulance - HCFA 1500, ambulance bill
Billing Provider Name & Address. Enter the name and address of the hospital/facility submitting the claim. 2. Pay to Address. Pay to address if different than field 1. 3a. Patient Control Number. Enter your facility's unique account number assigned to the patient, up to 20 alpha/numeric characters.
BENEXTEND CLAIM FORM INSTRUCTIONS. To avoid delays in processing of your claim form, complete each section attaching documentation below when it applies. Supporting Documentation Needed. Itemized bill if there was a hospital stay (UB04 from the hospital or medical facility)
UB-4 Claim Form and Instructions. ***This UB-04 claim form MUST be completed if you have a hospital, ER, or surgical claim***. The following are instructions to submitting a claim yourself: For self-submitted claims you will need to contact your provider to obtain all proper coding and information that are necessary to complete the required and ...
