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 February 20, 2021 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 American Hospital Association holds the copyright to the Official UB-04 Data Specifications Manual, which includes information adopted by the National Uniform Billing Committee. 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 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 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 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: Number of Administratively Necessary Days 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: Accident date 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 Was this page helpful? 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