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An Overview of the UB-04 Form

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An Overview of the UB-04 Form

Sample UB-04

What is the UB-04 form?

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
Tips for Preparing the UB-04

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 code

Form 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

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