Patient Rights Healthcare Team How the UB-04 Form Is Used to Bill Insurance Companies By Joy Hicks linkedin Joy B. Hicks, PhD, MBA, is an expert on the health insurance industry with over 15 years of experience in patient financial services. Learn about our editorial process Joy Hicks Updated on May 27, 2020 Print The UB-04 uniform billing form is the standard claim form that any institutional provider can use for the billing of medical and mental health claims. It's printed with red ink on white standard paper. Although developed by the Centers for Medicare and Medicaid (CMS), the form has become the standard form used by all insurance carriers. The National Uniform Billing Committee and the American Hospital Association design and modify the specifications for the Official UB-04 Electronic Data Set. They publish the UB-04 Manual. Hero Images / Getty Images Who Can Bill Claims Using the UB-04? Any institutional provider can use the UB-04 for billing medical claims. This includes: Community mental health centersComprehensive outpatient rehabilitation facilitiesCritical access hospitalsEnd-stage renal disease facilitiesFederally qualified health centersHistocompatibility laboratoriesHome health agenciesHospicesHospitalsIndian Health Services facilitiesOrgan procurement organizationsOutpatient physical therapy servicesOccupational therapy servicesSpeech pathology servicesReligious non-medical health-care institutionsRural health clinicsSkilled nursing facilities Tips for Preparing the UB-04 To fill out the form accurately and completely, be sure to do the following: Check with each insurance payer to determine what data is required.Ensure that all data is entered correctly and accurately 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) 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: 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 if it's different from field 1Form locator 3: Patient control number and the medical record number for your facilityForm locator 4: Type of bill (TOB). This is a four-digit code beginning with zero, according to the National Uniform Billing Committee guidelines.Form locator 5: Federal tax number for your facilityForm locator 6: Statement from and through dates for the service covered on the claim, in MMDDYY (month, date, year) format.Form locator 7: Not in useForm locator 8: Patient name in Last, First, MI formatForm locator 9: Patient street address, city, state, zip, and country codeForm locator 10: Patient birthdate in MMDDCCYY (month, day, century, year) formatForm locator 11: Patient sex (M, F, or U)Form locator 12: Admission date in MMDDCCYY formatForm locator 13: Admission hour using two-digit code from 00 for midnight to 23 for 11 p.m.Form locator 14: Type of visit: 1 for emergency, 2 for urgent, 3 for elective, 4 for newborn, 5 for trauma, 9 for information not available.Form locator 15: Point of origin (source of admission) Form locator 16: Discharge hour in the same format as line 13.Form locator 17: Discharge status using the two-digit codes from the NUBC manual.Form locator 18-28: Condition codes using the two-digit codes from the NUBC manual for up to 11 occurrences.Form locator 29: Accident state (if applicable) using two-digit state codeForm locator 30: Not in useForm locator 31-34: Occurrence codes and dates using the NUBC manual for codesForm locator 35-36: Occurrence span codes and dates in MMDDYY formatForm locator 37: Not in useForm locator 38: Responsible party name and addressForm locator 39-41: Value codes and amounts for special circumstances from the NUBC manualForm locator 42: Revenue codes from the NUBC manualForm 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 codesForm locator 45: Service datesForm locator 46: Service unitsForm locator 47: Total chargesForm locator 48: Non-covered chargesForm locator 49: Page_of_ and Creation dateForm locator 50: Payer Identification (a) Primary, (b) Secondary, and (c) TertiaryForm locator 51: Health plan ID (a) Primary, (b) Secondary, and (c) TertiaryForm locator 52: Release of information (a) Primary, (b) Secondary, and (c) TertiaryForm locator 53: Assignment of benefits (a) Primary, (b) Secondary, and (c) TertiaryForm locator 54: Prior payments (a) Primary, (b) Secondary, and (c) TertiaryForm locator 55: Estimated amount due (a) Primary, (b) Secondary, and (c) TertiaryForm locator 56: Billing provider national provider identifier (NPI)Form locator 57: Other provider ID (a) Primary, (b) Secondary, and (c) TertiaryForm locator 58: Insured's name (a) Primary, (b) Secondary, and (c) TertiaryForm locator 59: Patient's relationship (a) Primary, (b) Secondary, and (c) TertiaryForm locator 60: Insured's unique ID (a) Primary, (b) Secondary, and (c) TertiaryForm locator 61: Insurance group name (a) Primary, (b) Secondary, and (c) TertiaryForm locator 62: Insurance group number (a) Primary, (b) Secondary, and (c) TertiaryForm locator 63: Treatment authorization code (a) Primary, (b) Secondary, and (c) TertiaryForm locator 64: Document control number also referred to as Internal control number (a) Primary, (b) Secondary, and (c) TertiaryForm locator 65: Insured's employer name (a) Primary, (b) Secondary, and (c) TertiaryForm locator 66: Diagnosis codes (ICD)Form locator 67: Principle diagnosis code, other diagnosis, and present on admission (POA) indicatorsForm locator 68: Not in useForm locator 69: Admitting diagnosis codesForm locator 70: Patient reason for visit codesForm locator 71: Prospective payment system (PPS) codeForm locator 72: External cause of injury code and POA indicatorForm locator 73: Not in useForm locator 74: Other procedure code and dateForm locator 75: Not in useForm locator 76: Attending provider NPI, ID, qualifiers, and last and first nameForm locator 77: Operating physician NPI, ID, qualifiers, and last and first nameForm locator 78: Other provider NPI, ID, qualifiers, and last and first nameForm locator 79: Other provider NPI, ID, qualifiers, and last and first nameForm locator 80: RemarksForm locator 81: Taxonomy code and qualifier Was this page helpful? 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