Watch for the alerts in red text of the instructions that follow. The alerts contain key information to help guide you as well as other key policy matters that may have recently changed.
Instructions
Instructions for completing the UB-04 form follow. Items to be completed are either required or situational. Required information must be entered in order for the claim to process. Claims submitted with missing or invalid information in these fields will be returned unprocessed to the provider with a rejection letter listing the reason(s) the claims are being returned. These claims cannot be processed until corrected and resubmitted by the provider. Situational information is required (but only in certain circumstances as detailed in the instructions below). Optional means that entry of information is at the discretion of the provider. Claims should be submitted to:
Molina Medicaid Solutions P.O. Box 91021 Baton Rouge, LA 70821
Attention Hospital Providers: Two-Page Paper UB-04 Claims Now Accepted by LA Medicaid
UB04 Billing Instructions for ADHC Providers
UB04 Billing Instructions for End Stage Renal Disease
UB 04 Billing Instructions for Home Health Providers
UB 04 Billing Instructions for Hospice Providers
UB04 Billing Instructions for Hospital Providers
UB 04 Billing Instructions for Nursing Facility & ICF/IID