Contact the Provider Call Center at 1-800-932-0939.

Contact the Provider Assistance Center at 1-800-248-2152 or local at 717-975-4100

UB-04 Medical Invoice

The amount entered in FL 39-41 lines a-d for the Gross Patient Pay would be the amount from the PA 162.

Enter the amount reimbursed from Medicare paid for the Co-insurance Days in the billing period which can be taken off of the EOMB. Also if the recipient has a Third Party that was utilized you will combine the amounts from TPL and Medicare and list online in that field.

Yes, if a Long Term Care insurance policy is paying for services during the billing month, enter the information into FL 50, 54 line b, and the applicable FL 58 through 62.

Revenue Code lines on the UB-04 should be completed sequentially. DO NOT LEAVE BLANK LINES BETWEEN REVENUE CODES. Leaving blank lines between Revenue Codes will result in denial of the claim

Use the Admission Source Codes as it relates to their actual admission to the nursing facility. Refer to the UB-04 Desk Reference for Long Term Care Facilities (pdf download) for the appropriate Admission Source Codes.

The full Medicare Days should be entered on line 1 in this FL.

The specific name of the plan or insurance must be spelled out, ex; 1 Senior Blue. Refer to the Medical Assistance Billing Guide for complete instructions.


Refer to the appropriate billing guide for the type of bill information: for the UB-04 see FL 4; for 837 Institutional –Long Term Care, refer to loop 2300, segment CLM (Claim Information). When submitting claim adjustments, for the third character use a 7 for Type of Bill (TOB).

No, the only time the admission date would change is if the resident was discharged from the facility with no intention of returning but at a future date was admitted to the facility again.

Nursing facilities will use the following TOB codes:

  • 260 - Non-payment/Zero Claim
  • 261 - Admit Through Discharge Claim
  • 262 - Interim – First Claim
  • 263 - Interim – Continuing Claim
  • 264 - Interim – Last Claim
  • 267 - Replacement of a Prior Claim
  • 268 - Void/Cancel of a Prior Claim

ICFs/MR, ICFs/ORC and State ICFs/MR will use the following TOB codes:

  • 650 - Non-payment/Zero Claim
  • 651 - Admit Through Discharge Claim
  • 652 - Interim – First Claim
  • 653 - Interim – Continuing Claim
  • 654 - Interim – Last Claim
  • 657 - Replacement of a Prior Claim
  • 658 - Void/Cancel of a Prior Claim

All third party resources that might apply should be entered even if they do not apply during the service month. If a resident has four or more resources, enter the resources most relevant to long term care services.

Having two conditions codes would be possible if the recipient had two or more resources on file. The possible codes to list in condition code 18 & 19 would be X4, X2, and Y6. Please review the UB-04 billing guide.

You must wait until the claim is processed. Claims cannot be adjusted until they have been processed and paid.

You must always use the last paid ICN when adjusting a claim. However, if the last claim was a Void, you will have to submit a new claim.

Yes. The dates of service should include the full Medicare and non-covered days. The billing period for long term care providers equals one month or the last date of the month in which the service was provided and for which the facility is billing.

In accordance with regulation §1101.68(b)(3), the billing period for long term care providers equals 1 month or the last date of the month in which the service was provided and for which the facility is billing. Split billing will constitute a regulatory violation. Unless directed by the department, a provider should not split the bill.


There is no Revenue code for co-days but form locators 42,43,44,46 & 77 are must fields. Please follow the instructions below. (Also refer to the UB-04 billing guide.)

  • Form Locators 39a - 41d - When submitting a claim for a service period where all of the days are Medicare Coinsurance Days, using the appropriate value code in Form Locator 39a through 41d list all days within the service month that are Medicare Coinsurance days. Value codes should be entered in numerical sequence starting in Form Locators 39a through 41a, 39b through 41b, 39c through 41c and lastly 39d through 41d.
  • Form Locators 18 - 28 (Condition Codes) - Enter X2.
  • Form Locator 42 (Rev Cd) – Enter Revenue Code 0100.
  • Form Locator 43 (Description) – Enter Facility Days.
  • Form Locator 44 (HCPCS/Rate) – Enter the MA rate.
  • Form Locator 46 (Serv Units) – Enter a zero (0).
  • Form Locator 47 (Total Charges) – Enter the MA rate times the number of coinsurance days as the Total Charges. Also carry this figure down to Line 23 of Form Locator 47 in the Total field.

All other Form Locators on the UB-04 must be completed as per the billing guide

Days paid in full by Medicare are entered in FL 30 line 1. The amount in FL 54 of the UB-04 does not include amounts paid for days 1-100 (Full Medicare Days).

Yes, all Co-insurance days must be reported appropriately on the invoice with the corresponding payment.

Yes. You would enter Value Code 35 and the amount of the premium.

DHS is requesting the date of notification from Medicare on the status of your claim. MA is the payer of last resort. Providers shall not bill the program for services rendered until all other resources are exhausted. Refer to General Regulations §1101.64