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Claim Forms Please note: You will need to turn your Pop-Up Blocker off to access Provider Direct. Click here for more details. Recent claims information for providers. Please click on the links below to access the information you need. Should you have any questions please contact the Network Department at 704-721-7000 Last Updated: 12/12/2011

UB04 Billing Instructions Date Posted: 12/12/2011 PBH 837I (Institutional) Companion Guide 5010 Date Posted: 11/16/2011 PBH 837P (Professional) Companion Guide 5010 Date Posted: 11/16/2011 CMS1500 Billing Instructions Date Posted: 11/9/2011 PBH Health Insurance Form Date Posted: 11/9/2011 Place of Service Crosswalk Date Posted: 10/20/2011 Electronic Funds Transfer Form Date Posted: 10/7/2011 PBH 2011 Sliding Fee Schedule Date Posted: 10/5/2011 PBH Financial Status Report (FSR) Date Posted: 10/3/2011 PBH Claims Request Form Date Posted: 9/29/2011 Active Service List by Service Category Date Posted: 7/21/2011 PBH Reason Codes Date Posted: 6/9/2011 PBH 2010 Sliding Fee Schedule Date Posted: 2/21/2011 Provider Claim Inquiry Form Date Posted: 10/2/2008 Provider Refund Detail Form Date Posted: 9/18/2008

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