Wellmark Blue Cross Blue Shield of Iowa

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Complete all required areas of the UB-04 claim form.

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Use only original UB-04 claim forms with the red drop-out ink or file electronically.

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When using a printer, make sure the form is lined up correctly to facilitate electronic scanning.

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The value for all check boxes on the form is X.

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If a field is not completed, leave the items empty on the form.

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Do not enter zeros into numeric fields; leave the numeric fields empty unless specified.

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Claims are split into items based on the Revenue/HCPC Codes.

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Type – C (Commercial)

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Mode – R (Regular)

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Form – UB-04

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In the IDs to include in Paper Claims section, select the National Provider IDs (NPI) check box.

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In the IDs to include in EMC files section, select the National Provider IDs (NPI) check box.

Locator

Locator Name

Setup

N/A

Specialized Formats

Make no selection.

N/A

Printer

Select the appropriate printer.

N/A

General Rules

Select the Suppress dots & dashes in ICD codes, dates and insured info print variation.

FL 4

Type of Bill

Enter 0 to indicate the 4-digit type of bill using the claim constants at the appropriate level.

FL 6

Statement Cover Period From/Through Dates

Select the Use the first and last Dates of Service print variation.

FL 8

Patient Name/Identifier

Select the Print the middle initial only print variation.

FL 8a

Patient Name

Select the Print Patient Name print variation.

FL 10

Patient Birth Date

Select the Print Birth Date in MM/DD/YY format print variation.

FL 12

Admission Date

Select the Suppress printing Admission Date print variation.

FL 17

Patient Discharge Status

Select the Suppress printing of Patient Status Code print variation.

FL 18–28

Condition Code

If needed, enter condition codes in Patient>General>Claim Constants.

FL 31ab–34ab

Occurrence Code

Select the following print variations:

If additional codes need to be reported, refer to the NUBC Manual and enter them in Patient>General>Claim Constants.

FL 39–41

Value Codes Amounts

Enter value codes in Claims>Process>Annotate Claims or in Patient>General>Claim Constants.

FL 42

Revenue Code

Enter the appropriate 4-digit revenue codes in the Rev Code column in Administration>Financial>Billing Rates>Rates for this insurance.

Wellmark Blue Cross Blue Shield of Iowa billing is based on 15-minute units. Refer to the Wellmark Provider Guide for the appropriate revenue codes and units under this program.

N/A

Fee-for-service Claims

Select the Suppress printing of summary; print visit detail only print variation.

FL 51

Health Plan Identification Number

Select the Suppress printing Health Plan ID print variation.

FL 55

Estimated Amount Due

Select the Suppress printing estimated amount due print variation.

FL 59

Patient's Relationship to Insured

Select the Print NUBC Relationship Codes effective as of 10/01/11 print variation.

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In Administration>Financial>Insurance Codes>Print Variations, select the check box under FL 14–15 to ensure the ANSI 5010 Billing Template compliance.

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Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor(Release of Information) field in Patient>General>Payers>HIPAA.

Field

Description

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Yby default for each carrier. Change to N where applicable.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

-AND-
NPI

If your commercial carrier requires reporting attending physician, enter either the doctor's federal tax ID or Social Security Number.

Enter the agency's provider taxonomy code.

Enter the physician's NPI.

These fields are located in Resource>General>Roles.

Provider Taxonomy Code

Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes>General.

Submitter ID

Enter the submitter ID assigned by EC Solutions in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Receiver ID (Payer)
-OR-
Receiver ID (File Recipient)

Enter 88848 in the Receiver ID (Payer) field in Administration>Financial>Insurance Companies>Company or in the Receiver ID (File Recipient) field in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter WELLMARK BCBS of IA in the Receiver Name (Payer) field in Administration>Financial>Insurance Companies>Company or in Administration>Financial>Insurance Codes>EMC.

Request for paper EOB

To receive a paper EOB, select the Request Paper EOB check box in Administration>Financial>Insurance Codes>EMC.

Text Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent. If a file is created for production, do not select this check box.