Overview of the UB-04 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.

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

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-9 or ​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.

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 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.