Claim Page 04 – Entering a Hospice Claim
Claim Page 04 (Map 1714) provides space for you to key remarks that include pertinent information to assist the processing of the claim.
Key:
- RED = Required field
- BLUE = Optional field
- GREEN = Conditional field, dependent on the type of claim
- PURPLE = System generated field
- BLACK = Not required field
Field Descriptions for Claim Page 04 – Map 1714
The MID, TOB, S/Loc and PROVIDER fields are system generated from information on Claim Page 01.
Field Name/Requirement | UB-04 Form Locator | Description |
---|---|---|
REMARKS Optional | FL 80 | Enter any additional pertinent information to assist the processing of the claim.
Three pages are available to make remarks. Each page holds 10 lines of remarks. Press F6 to scroll forward to the next remark page. CGS may also use this field to relay information back to the provider when the claim is in process or processed. |
Additional FISS Claim Pages
- Notice of Elections (NOEs)/Transfer NOE
- Hospice Claims
- Notice of Election Termination/Revocation (NOTR) – 8XB
Updated: 04.13.21