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

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.