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UB-04 Billing Instructions Revision Table: Revision Date Sections Revised Description
UB-04 Billing Instructions Revision Table: Revision Date Sections Revised Description
Revision Table
1.0 Introduction
The Division of Medicaid and Medical Assistance (DMMA) establishes all policies and
procedures governing the Delaware Medical Assistance Program. The General Policy and
Provider Specific Policy manuals are to be referenced for all program guidelines.
HPES is the Delaware Medical Assistance Program Fiscal Agent. Providers are to bill HPES for
the care and services rendered to DMAP clients.
This Billing Manual has been designed as a reference tool to be utilized by DMAP providers
when submitting claims for payment. This manual should be used in conjunction with the
General Policy and Provider Specific Manuals. The submission of proper and complete billing
documents by providers is essential for timely and accurate claims processing and payment.
Initially, providers should carefully read this manual to become familiar with the contents. The
manual should then be referenced when completing billing documents or forms. HPES will
periodically update the Billing Manual on the DMAP Web site. Providers can opt to have paper
updates sent through the mail. Revised pages should be promptly inserted into the manual for
quick and accurate future reference.
This manual includes a chapter on the completion of claim forms and billing documents for all
provider types that bill using the UB-04 claim form.
UB-04 Provider Billing Manual
2.1 Introduction
The UB-04 claim form is used by inpatient and outpatient hospitals, long term care and assisted
living facilities, hospice, and home health providers in billing DMAP programs for services
provided to eligible Medicaid clients. Each client's services must be billed on a separate form.
The provider should carefully read and adhere to the following instructions so that claims can be
processed efficiently. Accuracy, completeness, and clarity are important.
• Use only original UB-04 claim forms with the red drop out
ink or file electronically.
HPES
2.7 Inclusions
When a client has third party insurance coverage, you must include a copy of the remittance
advice from the third party insurance carrier. If the carrier denied the claim, you must include
the denial remittance advice to show you have filed the claim.
Refer to the Provider Specific Section of this manual for a list of services that require inclusions.
If the claim does not have the appropriate inclusion, your claim will deny.
2.9 Sterilizations
Charges for deliveries and sterilizations must be combined on the same claim form. Please
refer to the Provider Specific Section of your Provider Manual for proper completion of
Consent/Awareness Forms.
99 - Not acceptable
UB-04 Provider Billing Manual