The UB-04 is the red-ink on white paper standard claim form used by institutional providers for claim billing. Although it was developed by The Centers for Medicare and Medicaid (CMS), it has become the standard form used by all insurance carriers.
Who Can Bill Claims using the UB-04?Any institutional provider can use the UB-04 for billing medical claims.
- Community Mental Health Center
- Comprehensive Outpatient Rehabilitation Facility
- Critical Access Hospital
- End-Stage Renal Disease Facility
- Federally Qualified Health Center
- Histocompatibility Laboratory
- Home Health Agency
- Hospice
- Hospital
- Indian Health Services Facility
- Organ Procurement Organization
- Outpatient Physical Therapy Services
- Occupational Therapy Services
- Speech Pathology Services
- Religious Non-Medical Health Care Institution
- Rural Health Clinic
- Skilled Nursing Facility
There are 81 fields or lines on a UB-04 referred to as form locators or "FL". Each form locator has a unique purpose.
Form locator 1 Billing provider name, street address, city, state, zip, telephone, fax, and country codeForm locator 2 Billing provider's pay-to name, address, city, state, zip, and ID
Form locator 3 Patient control number and medical record number
Form locator 4 Type of bill (TOB)
Form locator 5 Federal tax number
Form locator 6 Statement from and through dates
Form locator 7 Not in use
Form locator 8 Patient name
Form locator 9 Patient street address, city, state, zip, and country code
Form locator 10 Patient birthdate
Form locator 11 Patient sex
Form locator 12 Admission date
Form locator 13 Admission hour
Form locator 14 Type of visit
Form locator 15 Point of origin
Form locator 16 Discharge hour
Form locator 17 Discharge status
Form locator 18-28 Condition codes
Form locator 29 Accident state
Form locator 30 Not in use
Form locator 31-34 Occurrence codes and dates
Form locator 35-36 Occurrence span codes and dates
Form locator 37 Not in use
Form locator 38 Responsible party name and address
Form locator 39-41 Value codes and amounts
Form locator 42 Revenue codes
Form locator 43 Revenue code description, investigational device exemption (IDE) number, or medicaid drug rebate NDC (national drug code)
Form locator 44 HCPCS(Healthcare Common Procedure Coding System), accommodation rates, HIPPS (health insurance prospective payment system) rate codes
Form locator 45 Service dates
Form locator 46 Service units
Form locator 47 Total charges
Form locator 48 Non-covered charges
Form locator 49 Page_of_ and Creation date
Form locator 50 Payer Identification (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 51 Health plan ID (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 52 Release of information (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 53 Assignment of benefits (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 54 Prior payments (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 55 Estimated amount due (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 56 Billing provider national provider identifier (NPI)
Form locator 57 Other provider ID (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 58 Insured's name (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 59 Patient's relationship (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 60 Insured's unique ID (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 61 Insurance group name (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 62 Insurance group number (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 63 Treatment authorization code (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 64 Document control number also referred to as Internal control number (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 65 Insured's employer name (a) Primary, (b) Secondary, and (c) Tertiary
Form locator 66 Diagnosis codes (ICD)
Form locator 67 Principle diagnosis code, other diagnosis and present on admission (POA) indicators
Form locator 68 Not in use
Form locator 69 Admitting diagnosis codes
Form locator 70 Patient reason for visit codes
Form locator 71 Prospective payment system (PPS) code
Form locator 72 External cause of injury code and POA indicator
Form locator 73 Not in use
Form locator 74 Other procedure code and date
Form locator 75 Not in use
Form locator 76 Attending provider NPI, ID, qualifiers, and last and first name
Form locator 77 Operating physician NPI, ID, qualifiers, and last and first name
Form locator 78 Other provider NPI, ID, qualifiers, and last and first name
Form locator 79 Other provider NPI, ID, qualifiers, and last and first name
Form locator 80 Remarks
Form locator 81 Taxonomy code and qualifier
- Check with each insurance payer to determine what data is required.
- Ensure that all data is entered correctly and accurately in the correct fields.
- Most instructions for inpatient and outpatient services are the same. See the Uniform Billing Guide for specific details.
- Enter insurance information including the patient's name exactly as it appears on the insurance card.
- Use correct diagnosis codes (ICD-9 or upcoming ICD-10) and procedure codes (CPT/HCPCS) using modifiers when required.
- Use only the physical address for the service facility location field.
- Don't forget to include NPI information where indicated.
More detailed instructions can be found at www.cms.gov or www.nubc.org
