Iowa Medicaid Enterprise UB-04 Claim Form Health Insurance ...

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This field should be completed on the lastpage of the claim only.The total must include both dollars andcents.49 Untitled N/A Not Used50 A-C Payer Identification51 A-C*Health Plan ID52 A-C Release ofInformationCertification Indicator53 A-C Assignment ofBenefits CertificationIndicator54 A-C Prior PaymentsREQUIREDLEAVEBLANKOPTIONALOPTIONALEnter the designation provided by the stateMedicaid agency. Enter the name of eachpayer organization from which you mightexpect some payment for the bill. Whenindicating Iowa Medicaid as a payer, enter“Medicaid”.This field must be left BLANK.Entering information in this field will cause theclaim to be returned.By submitting the claim, the provider hasagreed to all information on the back of theclaim form, including release of informationNo entry requiredREQUIRED if prior payments were made bya payer other than Medicaid. If applicable,enter the amount paid by a payer other thanMedicaid.Do not enter previous Medicaid payments.The total must include both dollars andOPTIONAL cents.55 A-C Estimated AmountDue From Patient OPTIONAL No entry required56 * National Provider ID(NPI)REQUIRED57A *57B *57C *UntitledOtherProvider IDLEAVEBLANKEnter the NPI of the Billing entity.This field must be left BLANK. Enteringinformation in this field will cause the claim tobe returned.
58 Insured’s name59 Patient’s Relationshipto Insured60 A-C Insured’s unique IDREQUIREDOPTIONALEnter the last name, first name, and middleinitial of the Medicaid member on the line (A,B, or C) that corresponds to Medicaid fromField 50.No entry required.Required- Enter the member’s Medicaididentification number found on the MedicalAssistance Eligibility Card. It should consist ofseven digits followed by a letter, i.e.,1234567AEnter the Medicaid ID on the line (A, B, or C)REQUIRED that corresponds to Medicaid from Field 50.61 Group Name OPTIONAL No entry required62 A-C Insurance GroupNumber OPTIONAL No entry requiredEnter prior authorization number if applicable.63 TreatmentAuthorization CodeNOTE: This field is no longer used to reportthe MEDIPASS referral. Refer to Field 79 toenter the MEDIPASS referralSITUATIONAL Note: Lock-In moved to a Field 7864 Document ControlNumber (DCN OPTIONAL No entry required65 Employer nameOPTIONAL No entry required66 Diagnosis andProcedure codeQualifier (ICDVersion Indicator)67 Principal DiagnosisCodePresent onAdmission (POA)OPTIONALREQUIREDREQUIREDNo entry required. Medicaid only acceptsICD-9 codesEnter the ICD-9-CM code for the principaldiagnosis.POA indicator is the eighth digit of field 67 A-Q. POA indicates if a condition was presentor incubating at the time the order forinpatient admission occurs.Code Reason for CodeY Diagnosis was present at inpatientadmission.U Documentation insufficient to determine ifpresent at admission.
Page 1 and 2: Iowa Medicaid EnterpriseUB-04 Claim
Page 3 and 4: (non-hospital based)2 Hospice (hosp
Page 5 and 6: 14Type ofAdmission/VisitSITUATIONAL
Page 7 and 8: 72 Trans for Outpatient ServiceEnte
Page 9 and 10: Other11 Date of onset35-36 Occurren
Page 11: 46 Service UnitsSITUATIONALOutpatie
Page 15 and 16: 77 *78 *79 *QualLastFirstLEAVEBLANK
Page 17 and 18: Revenue CodesBOX 42CODE DEFINED SUB
Page 19 and 20: 24XAll InclusiveAncillary25XPharmac
Page 21 and 22: 35XCT Scan36XOperating RoomServices
Page 23 and 24: 45XEmergency Room46XPulmonary Funct
Page 25 and 26: (home health agencyonly)61XMRI62XMe
Page 27 and 28: (electroencephalogram)75XGastro-Int
Page 29: 92XOther DiagnosticServices94XOther

Iowa Medicaid Enterprise UB-04 Claim Form Health Insurance ...

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