Overview of the UB-04 Billing Claim Form

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.

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 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 health-care institutions
Rural health clinics
Skilled nursing facilities

Tips for Preparing the UB-04

To fill out the form accurately and completely, be sure to:

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 code
Form locator 2: Billing provider's pay-to name, address, city, state, zip, and ID if it's different from field 1
Form locator 3: Patient control number and the medical record number for your facility
Form 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 facility
Form 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 use
Form locator 8: Patient name in Last, First, MI format
Form locator 9: Patient street address, city, state, zip, and country code
Form locator 10: Patient birthdate in MMDDCCYY (month, day, century, year) format
Form locator 11: Patient sex (M, F, or U)
Form locator 12: Admission date in MMDDCCYY format
Form 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 code
Form locator 30: Not in use
Form locator 31-34 Occurrence codes and dates using the NUBC manual for codes
Form locator 35-36: Occurrence span codes and dates in MMDDYY format
Form locator 37: Not in use
Form locator 38: Responsible party name and address
Form locator 39-41: Value codes and amounts for special circumstances from the NUBC manual
Form locator 42: Revenue codes from the NUBC manual
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