1 Provider Name,Address, Telephone # Required. Enter the name and address of the facility 2 Pay to Name/Address/ID Situational. Enter the name, address, and Louisiana Medicaid ID of the provider if different from the provider data in Field 1.3a Patient Control No. Optional. Enter ...
13/16 Point of Origin Admission/Visit - FL 15 Patient Discharge Status - FL 17 Condition Codes - FLs 18-28 Occurrence Codes - FLs 31-34 Occurrence Span Codes - FLs 35-36 Value Codes and Amounts - FLs 39-41 Revenue Codes - FL 42 Code Codes - FL 81 Other UB04 Claim Form Codes ...