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

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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
Revenue CodesBOX 42CODE DEFINED S<strong>UB</strong>GATEGORIES11XRoom & BoardPrivate(medical or general)12XRoom & BoardSemi-Private TwoBed(medical or general)13XRoom & BoardSemi-Private Threeand Four Beds(medical or general)14XPrivate(deluxe)15XRoom & BoardWard(medical or general)16XOther Room &BoardCharges for accommodationswith a single bed.Charges for accommodationswith two beds.Charges for accommodationswith three and four beds.Charges for accommodationswith amenities substantially inexcess of those provided toother patients.Charges for accommodationswith five or more beds.Charges for accommodationsthat cannot be included in thespecific revenue centercodes. Hospitals that are0 General classifications1 Medical/surgical/GYN2 OB3 Pediatric4 Psychiatric6 Detoxification7 Oncology8 Rehabilitation9 Other0 General classifications4 Sterile environment7 Self care9 Other0 General classifications4 Sterile environment7 Self care9 Other0 General classifications4 Sterile environment7 Self care9 Other0 General classifications4 Sterile environment7 Self care9 Other0 General classifications4 Sterile environment7 Self care
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 and 12: 46 Service UnitsSITUATIONALOutpatie
Page 13 and 14: 58 Insured’s name59 Patient’s R
Page 15: 77 *78 *79 *QualLastFirstLEAVEBLANK
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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