LA · guidance
La. Medicaid Services Manual ch. 24 (Hospice), Appendix E
UB-04 Form and Instructions
The UB-04 claim form is required for billing Medicaid and is suitable for billing most third-party
payers (both government and private), because it serves the needs of many payers, some data
elements may not be needed by a particular payer. Detailed information is given only for items
required for Medicaid hospice claims. Items not listed need not be completed, although you may
complete them when billing multiple payees.
Claims for hospice services must be filed by electronic claims submission 837I or on the UB-04
claim form.
The most recent instructions for completing the UB-04 form along with samples of UB -04 claim
forms for hospice services routine billing are located on the home page of the Louisiana Medicaid
website. The billing instructions and examples may also be accessed at
http://www.lamedicaid.com/provweb1/billing_information/UB04_Hospice.pdf.
Provenance
- Source
- www.lamedicaid.com
- Retrieved
- 2026-10-01
- Edition
- msm-hospice-2025-12-23
- Content hash
3b454a2e71534d701d53262e83822455a244fc07a717af9211b45661b540ba71
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