Wednesday, September 29, 2010

UB 04 billing - Valid Claim format

Uniform Billing (UB) Claim form - Valid Claim format

DMAP only accepts commercially available versions of the UB-04 claim form. We will return claims submitted in other formats, Turn-Around Documents (TAD) or Extended Care Invoices (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.

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