# New FQHC Claim Submission



## nazcoder (Jun 9, 2014)

Greetings everyone;

Our facility was recently granted FQHC Status and now comes claim submission 

Per Field Locators and field entry on the UB-04 for electronic submission, can someone please verify if the following fields are correct? We are outpatient providing outpatient physician services only.

TOB = 0771
Admission Type = 3
Admission source = blank
Patient Status = 01 (Discharge to Home)
Revenue Code = 0521

Do I need the following on the UB-04?

Attending Provider
Admit and Discharge Date
Any other fields?

I thank and appreciate any and all responses. I went through CMS and it does not seem really clear on UB-04 claim submission in regards to FQHC Claims. I may be looking at the wrong place too inside CMS. Thank you all. Have a good day.


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## sbgill (Jun 24, 2014)

*UB Settings*

Our facility uses eClinicalWorks. This is how UB settings are:

UB Bill Type = 771
RevCode = 0521
AdmSourceCode = 9
AdmTypeCode = 9
PtStatusCode = 01
ZSendCasSegToMedicareA = yes

I hope this helps.


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## neelaprakash (Sep 17, 2014)

Hi Sbgill,
will it be alright if I contact you regarding FQHC billing?
Thanks


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