Participants 1
Module 3,
Topic 1
In Progress
HH06: RAP Claim Type – UB04 Form Examples Copy
Ian V. Chestnut July 26, 2021
Filling in a UB04 for a RAP
Type of Bill (TOB) (FL 4)
Priority (Type) of Admission or Visit Codes (FL 14)
- 1 Emergency
- 2 Urgent
- 3 Elective
- 4 Newborn
- 5 Trauma
- 9 Information Not Available
Point of Origin (formerly Source of Admission Codes) (FL 15)
- 1 Non-Health Care Facility Point of Origin
- 2 Clinic or Physician’s Office
- 4 Transfer from Hospital (Different Facility)
- 5 Transfer from Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
- 6 Transfer from Another Health Care Facility
- 8 Court/Law enforcement
- 9 Information not available
Patient Status Codes (FL 17)
Condition Codes (CC) (FL 18-28)
- 07 Treatment of nonterminal condition for hospice patient
- 20 Beneficiary requested billing (demand denial)
- 21 Billing for denial notice (no-pay bill)
- 47 Transfer from another HHA
- 54 No skilled HH visits in billing period.
- C3 Expedited review – partial approval of Medicare-covered services
- C4 Expedited review – services denied
- C7 Expedited review – extended authorization of Medicare-covered services
Value Code (FL 39-41)
