UB04 Forms – What they are and how to read them

By Ryan Jensen

When Denials Management, Inc. files a claim on your behalf, we use the UB-04 form for claim billing.  The UB-04 form is a form that any institutional provider can use for the billing of medical and mental health claims.  The UB-04 uniform billing form is on white standard paper with red ink, which is used by institutional providers for claim billing.   The UB-04 was created by The Centers for Medicare and Medicaid (CMS), and has developed and evolved into one of the most commonly used forms for billing a medical or mental health claim. The UB-04 form is also very popular among all insurance carriers. These days, the majority of UB-04 claims must be filed electronically.

The American Hospital Association and the National Uniform Billing Committee design, modify and update certain specifications for the UB-04 guidelines.  The American Hospital Association is a professional group that builds awareness, fairness, and quality among health care professionals and networks.

So what is the UB-04?

The UB-04 is the most current version of the uniform bill used by institutional providers. The UB-04 form provides improvements from the much needed UB-92 form.  Some of these improvements include:

  • increased the number of condition code fields from seven to eleven fields
  • there was a new field of ICD classifications created which can now be used ICD 9 and 10.
  • expansion of the diagnosis field sizes to accommodate ICD 10 codes.
  • expanded the number of fields for diagnoses to eighteen from nine.
  • revised physician fields to include specific fields for national provider Identifier # or (NPI) and first and last names, qualifications and Tax ID #’s
  • addition of three specific fields for patient’s reason for visit.

Certain Tips for preparing your UB-04

  • Make sure all data is entered correctly and accurately in the fields
  • Ensure each insurance payer to determine what data is needed or required, as each insurer may have different requirements
  • Use only the physical address for the service facility location field
  • Use the provider’s NPI and Tax ID information where indicated
  • Make sure you check the proper beneficiary in box 53. “Y” to the provider “N” to the member.

Fields of the UB-04

There are 81 fields—or lines—on a UB-04 referred to as form locators or “FL.” Each form locator has a unique purpose for the insurance carrier and provider so that they can communicate.

-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 is 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 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 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 pm

-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 same format as line 13.

-Form locator 17 Discharge status – use the two-digit codes from the NUBC manual.

-Form locator 18-28 Condition codes – use the two-digit codes from the NUBC manual for up to 11 occurrences.

-Form locator 29 Accident state (if applicable) two-digit state code

-Form locator 30 Not in use

-Form locator 31-34 Occurrence codes and dates – use 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 charge

-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

Follow this UB04 Demo pdf to see these boxes explained on a real form!

 Final Steps: Make sure UB-04 format is correct with accurate data in correct form location

A majority of payers accept photocopied or black and white UB-04 medical claims. If you mail in your UB-04, I would recommend sending in the original form with the “red ink” and keep the photo copy for yourself.  Sometimes if you mail in a form it may not scan into their system properly, creating a delay, mishandling, or denial in payment. Electronically, it is a little friendlier in terms of ink.  You don’t want to highlight any information on the claim, nor do you want to hand write comments on the UB-04 form.  You will want to enter the insurance information on the UB-04, including the patient’s name, exactly as it appears on the insurance card. Again, many large commercial payors now require these forms to be filed electronically directly from a provider or third party billing agency.

Last but not Least: Attach the correct documentation

We usually submit what is only required, and that is the UB-04 form and itemized statements and invoices for medical or mental health services. If the insurance company asks for more medical information such as medical history, medical records, primary payer explanation of benefits, or proof of accident, injury or treatment, those records will also be forwarded per the carrier’s request.








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