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

NPIQualLastFirst80 * RemarksSITUATIONALLEAVEBLANKSITUATIONALSITUATIONALREQUIRED if the patient is in the MediPASSprogram or if Non-MediPASS and claim isOutpatient- Enter the NPI of the referringphysician. This area should not be completedif the primary physician did not give thereferral.This field must be left BLANK. Enteringinformation in this field will cause the claim tobe returned.Enter the last name of the referringMediPASS physician.Enter the first name of the referringMediPASS physician.REQUIRED if a diagnosis other than theprincipal is made.SITUATIONAL When applicable enter one of the following:- “Not a Medicare Benefit”- “Resubmit” (and list the original filing date)81 * Code-Code Fields- Member is “Retro-Eligible and NOD isattached” (notice of decision).REQUIRED – Enter taxonomy codeassociated with the NPI of the billing entity(Field 56). Precede taxonomy code withqualifier “B3” (healthcare provider taxonomycode).REQUIREDNote: the taxonomy code must match thetaxonomy code confirmed during NPIverification or during enrollment.Updated 4/17/12