How the UB-04 Form Is Used to Bill Insurance Companies

The UB-04 uniform medical billing form is the standard claim form that institutional providers use, such as hospitals and community mental health care centers. It is used to bill Medicare, Medicaid, and other health insurance companies for inpatient or outpatient services.

Although developed by the Centers for Medicare and Medicaid Services (CMS), the paper form has become the standard claim form used by all insurance carriers. The National United Billing Committee, the governing body for medical claims billing forms, is responsible for the design and printing of the UB-04 form.

This article explains who can fill out the form and what the form's various sections mean.

Doctor with medical record in her hands — Hero Images / Getty Images

Who Can Bill Claims Using the UB-04?

Any institutional provider can use the UB-04 for billing medical claims. Non-institutional providers or suppliers, such as physicians or providers of durable medical equipment, use the CMS-1500 form.

Institutional providers that can use the UB-04 form include:

Community mental health centers
Comprehensive outpatient rehabilitation facilities
Critical access hospitals
End-stage renal disease facilities
Federally qualified health centers
Histocompatibility laboratories
Home health agencies
Hospices
Hospitals
Indian Health Services facilities
Organ procurement organizations
Outpatient physical therapy services
Occupational therapy services
Speech pathology services
Religious non-medical healthcare institutions
Rural health clinics
Skilled nursing facilities

How Is the UB-04 Form Different Than an Itemized Bill?

An itemized medical bill lists in detail all the services that were provided during a visit or stay—such as a blood test or physical therapy—and may be sent to the patient directly. The UB-O4 form is used by institutions to bill insurance companies.

Tips for Preparing the UB-04

To fill out the form accurately and completely:

Check with each insurance payer to determine what data is required.
Ensure that all data is entered accurately and in the correct fields.
Enter insurance information, including the patient's name exactly as it appears on the insurance card.
Use correct diagnosis codes (ICD-10 or ICD-11) and procedure codes (CPT/HCPCS) using modifiers when required.
Use only the physical address for the service facility location field.
Include National Provider Identifier (NPI) information where indicated.

More detailed instructions can be found at www.cms.gov or www.nubc.org.

Fields of the UB-04

There are 81 fields or lines on a UB-04. They're referred to as form locators or "FL." Each form locator has a unique purpose:

1: Billing provider name, street address, city, state, zip, telephone, fax, and country code
2: Billing provider's pay-to name, address, city, state, zip, and ID if it's different from field 1
3: Patient control number and the medical record number for your facility
4: Type of bill (TOB). This is a four-digit code beginning with zero, according to the National Uniform Billing Committee guidelines.
5: Federal tax number for your facility
6: Statement from and through dates for the service covered on the claim, in MMDDYY (month, date, year) format
7: Number of Administratively Necessary Days
8: Patient name in Last, First, MI format
9: Patient street address, city, state, zip, and country code
10: Patient birthdate in MMDDCCYY (month, day, century, year) format
11: Patient sex (M, F, or U)
12: Admission date in MMDDCCYY format
13: Admission hour using a two-digit code from 00 for midnight to 23 for 11 p.m.
14: Type of visit: 1 for emergency, 2 for urgent, 3 for elective, 4 for newborn, 5 for trauma, 9 for information not available

15: Point of origin (source of admission)
16: Discharge hour in the same format as line 13
17: Discharge status using the two-digit codes from the NUBC manual
18-28: Condition codes using the two-digit codes from the NUBC manual for up to 11 occurrences
29: Accident state (if applicable) using a two-digit state code
30: Accident date
31-34: Occurrence codes and dates using the NUBC manual for codes
35-36: Occurrence span codes and dates in MMDDYY format
37: Not in use
38: Responsible party name and address
39-41: Value codes and amounts for special circumstances from the NUBC manual
42: Revenue codes from the NUBC manual
43: Revenue code description, investigational device exemption (IDE) number, or Medicaid drug rebate NDC (national drug code)
44: HCPCS Healthcare Common Procedure Coding System), accommodation rates, HIPPS (health insurance prospective payment system) rate codes
45: Service dates
46: Service units
47: Total charges
48: Non-covered charges
49: Page_of_ and Creation date

50: Payer Identification (a) Primary (b) Secondary and (c) Tertiary
51: Health plan ID (a) Primary (b) Secondary and (c) Tertiary
52: Release of information (a) Primary (b) Secondary and (c) Tertiary
53: Assignment of benefits (a) Primary (b) Secondary and (c) Tertiary
54: Prior payments (a) Primary (b) Secondary and (c) Tertiary
55: Estimated amount due (a) Primary (b) Secondary and (c) Tertiary
56: Billing provider national provider identifier (NPI)
57: Other provider ID (a) Primary (b) Secondary and (c) Tertiary
58: Insured's name (a) Primary (b) Secondary and (c) Tertiary
59: Patient's relationship (a) Primary (b) Secondary and (c) Tertiary
60: Insured's unique ID (a) Primary (b) Secondary and (c) Tertiary
61: Insurance group name (a) Primary (b) Secondary and (c) Tertiary
62: Insurance group number (a) Primary (b) Secondary and (c) Tertiary
63: Treatment authorization code (a) Primary (b) Secondary and (c) Tertiary
64: Document control number also referred to as Internal control number (a) Primary (b) Secondary and (c) Tertiary

65: Insured's employer name (a) Primary (b) Secondary and (c) Tertiary
66: Diagnosis codes (ICD)
67: Principle diagnosis code, other diagnosis, and present on admission (POA) indicators
68: Not in use
69: Admitting diagnosis codes
70: Patient reason for visit codes
71: Prospective payment system (PPS) code
72: External cause of injury code and POA indicator
73: Not in use
74: Other procedure code and date
75: Not in use
76: Attending provider NPI, ID, qualifiers, and last and first name
77: Operating physician NPI, ID, qualifiers, and last and first name
78: Other provider NPI, ID, qualifiers, and last and first name
79: Other provider NPI, ID, qualifiers, and last and first name
80: Remarks
81: Taxonomy code and qualifier

Summary

Institutions use the UB-04 form to bill insurance for inpatient or outpatient medical and mental health claims. Examples include hospitals, hospices, rural health clinics, and comprehensive outpatient rehabilitation facilities. When filling out the form, be sure to understand the meaning of each of the 81 fields and to make sure that the information is accurate.

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