Claim Page 04 — Entering a Hospice Claim

Claim Page 04 (Map 1714) provides space for you to key remarks that include pertinent information to assist the processing of the claim.

FISS Claims Entry Page 4, entering hospice claims

Key:

RED = Required field
BLUE = Optional field
GREEN = Conditional field, depended on the type of claim
PURPLE = System generated field
BLACK = Not required field

Field Descriptions for Claim Page 04 – Map 1714

The HIC, TOB, S/LOC, and PROVIDER fields are system generated from information on Claim Page 01.

Field Name / Requirement	Description
REMARKS Optional	Enter any additional pertinent information to assist the processing of the claim. On transfer claims, hospices are required to include the name and address of the hospice the patient is transferring to/from. Include the date of the remark and your initials. Three pages are available to make remarks. Each page holds 10 lines of remarks. Press F6 to scroll forward to the next remark page. Cahaba may also use this field to relay information back to the provider when the claim is in process or processed.

Field Name / Requirement

Description

REMARKS
Optional

Enter any additional pertinent information to assist the processing of the claim. On transfer claims, hospices are required to include the name and address of the hospice the patient is transferring to/from. Include the date of the remark and your initials. Three pages are available to make remarks. Each page holds 10 lines of remarks. Press F6 to scroll forward to the next remark page. Cahaba may also use this field to relay information back to the provider when the claim is in process or processed.

Page last updated: March 18, 2008