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

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A4 Family planningA5 DisabilityA6 Vaccine/Medicare 100% paymentA7 Induced abortion – danger to lifeA8 Induced abortion – victim rape/incestA9 Second opinion surgeryHome Health Agency (Medicare notapplicable)XA Condition stableXB Not homeboundXC Maintenance careXD No skilled service29 Accident State OPTIONAL No entry required30 Untitled OPTIONAL No entry required31-34 Occurrence Codesand DatesREQUIRED if any of the occurrences listedbelow are applicable to this claim, enter thecorresponding code and the month, day, andyear of that occurrence.Accident Related01 Auto accident02 No fault insurance involved, including autoaccident/other03 Accident/tort liability04 Accident/employment related05 Other accident06 Crime victimSITUATIONALInsurance Related17 Date outpatient occupational planestablishedor reviewed24 Date insurance denied25 Date benefits terminated by primary payer27 Date home health plan was established orlastreviewedA3 Medicare benefits exhausted
Other11 Date of onset35-36 Occurrence SpanCode and Dates OPTIONAL No entry required37 Untitled OPTIONAL No entry required.38 Untitled (Responsibleparty name andaddress)39-41 Value Codes andAmountsOPTIONALNo entry required.REQUIRED – Enter the value code, followedby the NUMBER of covered and/or noncovereddays that are included in the billingperiod. (NOTE: there should not be a dollaramount in this field).If more than one value code is shown for abilling period, codes are shown in ascendingnumeric sequence.42 Revenue CodeREQUIRED80 Covered days81 Non-Covered daysEnter the revenue code that corresponds toeach item or service billed.A list of valid revenue codes can be found atthe end of these UB-04 claim forminstructions.REQUIREDNote:Not all listed revenue codes are payable byMedicaid.
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: 72 Trans for Outpatient ServiceEnte
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 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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