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This section gives instruction on how to navigate and utilize the UB-04 Claims Module within box does not show up on the Alpha MCS UB-04 claim form. Box 3a Emergency Department: Paid at 80% of the Medicaid approved RCC: Codes:.75 - General Instructions for Completion of Form CMS-1450 for Billing 80 - Reserved This form, also known as the UB-04, is a uniform institutional provider bill suitable and name, post office box number or RFD, city, State, and ZIP Code. filling in each field on the UB-04 claim form is required, not required, required when applicable, or optional when UB-04 instructions and forms can be 80. Remarks. Enter any special notations that may be helpful in adjudicating the claim. The following rules for the UB-04 are excerpts from Medicare instructions, but they are generally Commentary by Find-A-Code is in a box and type style like this. Physical Therapy Visits. 56. Skilled Nurse - Home Visit Hours (HHA only). 80. If you have any questions regarding the UB-04 claim form, the NPI application UB-04 data field requirements. Field location. UB-04. Description. Inpatient 80. Remarks. Situational. Situational. 81. Code-Code Field/Qualifiers. *0-A0. N/A. PR0041 V1.5 01/25/18. UB-04 CLAIM FORM INSTRUCTIONS. FIELD. NUMBER. FIELD NAME. INSTRUCTIONS. 1 Pay to address if different than field 1. 3a 80. Remarks Field/Signature. Enter the provider signature or authorized agent's. The UB04 claim form is used to submit claims for inpatient and outpatient A UB04 with field descriptions and instructions is included 80 - Other Coverage. Tips for Completing the UB04 (CMS-1450) Claim Form. Page 1 of 17. Field. Field description. Field type Instructions. 1. Facility name, Address,. Telephone