Valid claim formats
DMAP only accepts commercially-available “red form” versions of the UB-04 claim form. We will return claims submitted on the UB-92 form, black-and-white copies of the UB-04 form, Turn-Around Document (TAD) or Extended Care Invoice (DHS 1039) with a request to resubmit the claim on the correct form.
DMAP processes hardcopy claims using Optical Character Recognition (OCR) scanning. To avoid processing delays, make sure information is left-aligned in the following fields:
4 – Type of Bill
6 – Statement From and Through Dates
8b – Patient Name
If your forms are not to scale, or if the fields on your form are not correctly aligned, DMAP will manually enter your claim, which may delay processing of the claim.
Box : 3a
Field :Patient Control No.
Description : If a patient account number is provided in this box, DMAP will print it on the Remittance Advice (RA).
Box : 4
Field :Type of Bill
Description : Enter the appropriate three (3)-digit code that identifies the type of service you are billing for.
See the “Type of Bill Codes” section of the Appendix for specific codes by provider type, or refer to the provider guidelines for your program.
Box : 6
Field : Statement Covers Period
Description : Enter the beginning and ending dates of service covered by this claim. Use MDDYY numeric format (example: 102808). Total days in this field must correspond to the number of units in FL 46. • “From” date is the date services began. • “Through” date is the date services ended
Notes for nursing facilities:
Medicare Part A and Part B claims should include the “From” and “Through” dates as indicated on the Medicare payment listing or EOB. • The Statement Covers Period must be a continuous period of time. A new UB-04 must be submitted each time there is a Break in Service.
Box : 7
Field : Crossover indicator
Description : Enter “XOVR” for Medicare Part B claims.
Box : 8b
Field Location : Patient Name
Description : Enter the recipient name exactly as it is printed on the Medical Care ientification. DO NOT use “nicknames”.
Box : 12
Field Location : Admission Date
Description : Enter the actual admission date. Use MMDDYYYY format.
Box : 13
Field Location : Admission Hour
Description : For inpatient and outpatient hospital services, enter the hour of admission. Use numbers from 00 to 24 (01 = 1 a.m., 10 = 10 a.m., 13 = 1 p.m. 23 = 11 p.m., etc.).
Box : 14
Field Location : Type of Admission or Service
Description : For inpatient hospital services, enter the one (1)-digit code to indicate type of service. Use one of the following codes (see OAR 410-125-0401 for definitions): • 1 – Emergent • 2 – Urgent • 3 – Elective • 4 – Newborn
Box : 16
Field : Discharge Hour
Description : For inpatient and outpatient hospital services, enter the hour of discharge. Use numbers from 00 to 24 (01 = 1 a.m., 10 = 10 a.m., 13 = 1 p.m. 23 = 11 p.m., etc.).
Box : 17
Field : Patient Status
Description : For inpatient hospital and nursing facility services, enter the two (2)-digit code to indicate patient status at time of discharge. See Appendix for a list of codes.
Box : 31-34
Field : Occurrence Date
Description : For SNF and PHEC services, enter the two (2)-digit code to indicate the type of occurrence, followed by the date of the occurrence. Use MMDDYYYY format. • 01 – Auto accident • 04 – Employment-related accident
Box : 35-36
Field: Occurrence Span
Description : For SNF and PHEC services, enter the two (2)-digit code to indicate the type of occurrence, followed by the beginning and end dates of the occurrence. Use MMDDYYYY format.
• 70 – Qualifying Hospital Stay Dates for SNF (FL 35): Enter the date the resident was admitted to the hospital and the date the resident discharged from the hospital.
• Note: Occurrence code 70 and qualifying dates must be entered in FL 35 or 36 in order to receive payment for skilled nursing facility coinsurance or for the 20-day post hospital extended care (PHEC) benefit.
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