29-I Health Facility Billing Tool

FORM UB-04

The MCTAC 29-I Health Facility Billing tool is an interactive UB-04 form that walks through the components required to submit a clean claim for Core Limited Health Related Services and Other Limited Health Related Services. Whether you are new to the process or just want to quickly check one field, the billing tool is the ideal reference.

This tool will tell you what information is required for each field and will note specific plan requirements. 

Reminder:
Core Limited Health Related Services are always billed directly to the Medicaid Managed Care Plan that you, the provider, are contracted with and not the delegate (Beacon or other subcontractor).
For Other Limited Health Related Services, providers need to review their contract and talk with MMCP to determine who to submit a claim to as this varies across plans.     

For additional information regarding billing please refer to the 29-I Health Facility Billing Guidance.

If you are looking for clean claim information on billing other services, separate from 29-I please view the general MCTAC Billing Tool. 

Hover over or click each numbered field for more information.