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

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17XNursery18XLeave of Absence20XIntensive Care21XCoronary Care22XSpecial Charges23XIncremental NursingCharge Rateseparating this charge forbilling Sterile environment isto be usedCharges for nursing care fornewborn and prematureinfants in nurseries.Charges for holding aroom/bed for a patient whilethey are temporarily awayfrom the provider.Charges for medical orsurgical care provided topatients who require a moreintensive level of care than isrendered in the generalmedical or surgical unit.Charges for medical careprovided to patients withcoronary illnesses requiring amore intensive level of carethan is rendered in thegeneral medical care unit.Charges incurred during aninpatient stay or on a dailybasis for certain services.9 Other0 General classification1 Newborn2 Premature5 Neonatal ICU9 Other5 Nursing home (forhospitalization)0 General classification1 Surgical2 Medical3 Pediatric4 Psychiatric6 Post ICU7 Burn care8 Trauma9 Other intensive care0 General classification1 Myocardial infarction2 Pulmonary care3 Heart transplant4 Post CCU9 Other coronary care0 General classification1 Admission charge2 Technical support charge3 U.R. service charge4 Late discharge, medicallynecessary9 Other special charges0 General classification1 Nursery2 OB3 ICU4 CCU
24XAll InclusiveAncillary25XPharmacy26XIV Therapy27XMedical/SurgicalSupplies andDevices(also see 62X, anextension of 27X)28XOncologyA flat rate charge incurred oneither a daily or total staybasis for ancillary servicesonly.Charges for medicationproduced, manufactured,packaged, controlled,assayed, dispensed, anddistributed under direction oflicensed pharmacies.Equipment charge oradministration of intravenoussolution by specially trainedpersonnel to individualsrequiring such treatment.This code should be usedonly when a discrete serviceunit exists.Charges for supply itemsrequired for patient care.Charges for the treatment oftumors and related diseases.9 Other0 General classification9 Other inclusive ancillary0 General classification1 Generic drugs2 Nongeneric drugs3 Take home drugs4 Drugs incident to otherdiagnostic services5 Drugs incident to radiology6 Experimental drugs7 Nonprescription8 IV solutions9 Other pharmacy0 General classification1 Infusion pump2 IV therapy/pharmacy services3 IV therapy/drug/supply delivery4 IV therapy/supplies9 Other IV therapy0 General classification1 Nonsterile supply2 Sterile supply3 Take home supplies4 Prosthetic/orthotic devices5 Pacemaker6 Intraocular lens7 Oxygen – take home8 Other implants9 Other supplies/devices0 General classification9 Other oncology29X Charges for medical 0 General classification
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 and 16: 77 *78 *79 *QualLastFirstLEAVEBLANK
Page 17: Revenue CodesBOX 42CODE DEFINED SUB
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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