part ii policies and procedures for rural health clinic services

Completion of the National Uniform Billing Claim Form (UB-04 92)FL 1FL 3FL 4Provider Name, Mailing Address, and Telephone NumberEnter the name of the provider submitting the bill, the complete mailing address,and telephone number.Patient Control NumberEnter the patient‟s unique alphanumeric number assigned by the provider tofacilitate retrieval of individual case records and posting of payment.Type of BillEnter code 711 to indicate the specific type of bill.Type of FacilityAlways use „7‟ for rural health services.Bill ClassificationMust be „1‟ (Rural Health)FrequencyThe only acceptable rural health clinic frequency is “1”.FL 6FL 12FL 13FL 14Statement Covers PeriodEnter the beginning and ending service date of the period included on this bill.Patient NameEnter last name, first name, and middle initial of the patient. If the name on theMedicaid card is incorrect, the member or the member‟s representative shouldcontact the local DFCS to have it corrected immediately.Patient AddressEnter the full mailing address including street number and name of post office boxnumber or RFD, city name: state name; zip code.Patient Birth DateRecord date of birth exactly as it appears on the Medicaid card. An unknown birthdate is not acceptable. If the date on the Medicaid card is incorrect, the member orthe member‟s representative should contact the DFCS to have it correctedimmediately.January 2012 Rural Health Clinic Services E-11