Required Fields on Paper UB-04
{"Image DocumentName": "Required Fields on Paper UB-04", "Image ImageDescription": "Field 37: UNLABELED FIELD. This field contains the Care Select primary medical provider (PMP) two-character alphanumeric certification code for the dates of service rendered. Required for IHCP members enrolled in Care Select, when the service is not rendered by the member s PMP. Some services, including those considered self-referral, are exempt from the certification code requirement (see IHCP Provider Manual, Chapter 1) If certification code is required, report PMP s National Provider Identifier (NPI) in field 78. Fields 39a-41d: VALUE CODES. Use these fields to indicate Medicare Remittance Notice (MRN) information. Use ONLY when it is a true Medicare Crossover (not a Medicare Replacement Plan) A1 Medicare deductible amount. A2 Medicare coinsurance amount. 06 Medicare blood deductible. Also use Value Code 80 to indicate the number of IHCP covered days.", "Image XResolution": "37", "Image YResolution": "37", "Image ResolutionUnit": "Pixels/Centimeter", "Image Software": "SlidePlayer", "Image YCbCrPositioning": "Centered"}