Ind. IHCP Hospice Services Provider Reference Module, Section 6, Completion of Continuation Claim Using UB-04 Claim Form

The UB-04 claim form has only 22 lines, so an entire month cannot be billed on one page. However, the

hospice provider has the option to prepare a continuation claim. A continuation claim has more than one

UB-04 claim form, but must be completed as if it is one claim for payment by CoreMMIS. The hospice

provider must complete the continuation claim as follows:

1. Mark the first UB-04 claim form page 1 of 2 on line 23 of the form.

2. Complete the first 22 lines of the UB-04 claim form.

3. Do not subtotal the first page of the claim (only the last page of the continuation claim must be

totaled or CoreMMIS reads the claim as two claims rather than one).

4. Mark the second UB-04 claim form page 2 of 2 on line 23.

5. Complete the second UB-04 claim form for remaining dates of service for the month.

6. Provide a grand total for the continuation claim on the second UB-04 claim form.

7. Rotate the second UB-04 claim form (end to end) and place under the first UB-04 claim form. Do

not staple or paperclip.

If the hospice provider does not want to complete a continuation claim, the hospice provider has the option

to complete two separate UB-04 claim forms. The first claim form has enough space for the hospice

provider to bill for the first 22 days of service for the month. The hospice provider totals the daily amounts

for a grand total. The hospice provider then completes a second UB-04 claim form for the remaining days

of service for the month, and totals the daily amounts for a grand total.

See the Claim Submission and Processing module for more information about the IHCP claim process.