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How the UB-04 Form Is Used to Bill Insurance Companies
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James Lacy, MLS, is a fact-checker and researcher. James received a Master of Library Science degree from Dominican University.
The UB-04 uniform medical billing form is the standard claim form that any institutional provider can use for the billing of inpatient or outpatient medical and mental health claims. It is a paper claim form printed with red ink on white standard paper. Although developed by the Centers for Medicare and Medicaid Services (CMS), the form has become the standard form used by all insurance carriers.
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
- 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
A Word From Verywell
While the UB-04 form is intended mainly for institutional providers to bill insurance companies, it's never a bad idea to inform yourself about what goes into medical claims. If you see something you don't understand, ask your insurer or provider to explain it to you.
Frequently Asked Questions (FAQs)
Is there a difference between the ub-04 and an itemized bill.
An itemized medical bill lists in detail all the services that were provided during a visit or stay—such as a blood test or physical therapy—and may be sent to the patient directly. The UB-O4 form is used by institutions to bill Medicare or Medicaid and other insurance companies.
What is the difference between the UB-04 and the CMS 1500 forms?
The UB-04 form is used by institutional providers, such as nursing homes and hospitals, while the CMS-1500 form is the standard claim form used by a non-institutional provider or supplier, such as a physician or a provider of durable medical equipment.
Who is responsible for developing data elements reported on the UB-04?
The National United Billing Committee (NUBC) is a voluntary and multidisciplinary committee that develops data elements for claims and transactions. The NUBC is responsible for the design and printing of the UB-04 form.
National Uniform Billing Committee. National Uniform Billing Committee Official Data Specifications Manual .
Centers for Medicare and Medicaid Services. Professional paper claim form (CMS-1500)
By Joy Hicks Joy B. Hicks, PhD, MBA, is an expert on the health insurance industry with over 15 years of experience in patient financial services.
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A Complete Guide to UB-04 Forms for Healthcare Providers
Running a healthcare facility is an ever-evolving job, and proper processing of a patient’s medical claim is one of the most important tasks. Due to compliance and insurance regulations, submitting correct claims can be a challenge –especially with detailed required forms such as the UB-04 form. Currently, 98% of hospital claims for healthcare providers such as hospitals are submitted electronically using UB-04 forms – but the process of filling them out is still manual for many providers. What if you had a billing solution that could process your UB-04 forms electronically?
Logik Solutions’ UB-04 Form Capabilities
Logik can satisfy payer requirements for healthcare billing by helping you as the provider generate standard and customized bills and forms ensuring you get paid on time, every time. In addition, we have expertise in the special formats, rules and revenue codes that are unique to behavioral health billing.
Logik is one of only a few billing solutions with the exclusive ability to process UB-04 forms electronically and automatically within our software.
UB-04 forms, as with any medical form, can be complex and requires specific information to complete correctly. So, let’s look at what role UB-04 forms play in healthcare agencies, how to best utilize them, and how Logik’s complete billing solution can help.
What Are UB-04 Forms?
The UB-04 Form, maintained by the National Uniform Billing Committee (NUBC), is a standard claim form used by institutional providers to bill healthcare claims. The Claim Form, also known as the CMS 1450 claim form, was created by The Centers for Medicare and Medicaid (CMS). Since its creation, the form has advanced to being predominantly used in the healthcare space and is well known by insurance agencies.
What is the Importance of UB-04 Forms to Healthcare Providers?
The UB-04 claim form is crucial because it is used by many of the major insurance companies for a wide range of patient conditions and treatments. While it can be complicated as we have stated before, it is a better alternative than merging different forms together, and cuts down the administrative workload for you and your billing staff. Maximizing patient claims is a surefire way to maintain a steady revenue stream to help you combat other healthcare frictions (e.g., payer mix changes, regulatory oversight, etc.)
Tips for Filling out the UB-04 Form
- Check out your insurance company’s requirements since there can be some differences between insurance providers.
- Know the 10-digit pin of your National Provider Identifier (NPI) number and the necessary tax ID numbers.
- Learn the difference between Form Locators (FLs). They are the 81 separate fields on the UB-04 Form.
- Understand when to use specific procedure codes and diagnosis codes.
- Always consult with the NUBC manual for accurate codes.
- Check with insurance companies to ensure that your data is accurate.
- Use the appropriate ICD-10 codes when required.
- Always enter patient information exactly how it appears on their insurance card.
The Difference Between the UB-04 Form and the CMS- 1500
While these two forms were created for the same purpose of uniform billing and administrative simplicity, there are some obvious differences in coding structure and form layout. Sometimes, it’s difficult to tell apart the form you are supposed to use when taking on a patient’s medical claims. The UB-04 is for healthcare systems, and CMS-1500 is for individual providers. In other words, if you work in a behavioral healthcare practice or clinic setting, you will use the UB-04. If you are a physician or a doctor, you should use the CMS-1500 claim form to complete your billing.
Breaking Down the Fields of the UB-04 Form
The UB-04 claim form has over 80 fields known as Form Locators (FLs). Every field of the UB-04 has a specific purpose and requires unique information. Below are tips to help you understand some of the form locators:
Form Locator 1 :
- Line 1: Provider Name
- Line 2: Street Address
- Line 3: City, State, and Zip
- Line 4: Telephone Number, Fax Code, and Country Code
Form Locator 2 : You only need to fill out this form if the pay-to name is different from field 1.
- Line 1: Pay-to Name
- Line 4: NOT USED
Form Locator 3 (a/b) : Enter the patient number & medical record number
Form Locator 4 : This is where you enter the type-of-bill (TOB). This is a four-letter code that determines the specific type of bill (e.g., outpatient, inpatient, etc.) The first digit is a zero, the second two digits indicate the type of bill, and the fourth number indicates the frequency of the bill.
Form Locator 5 : This is for your federal tax number.
Form Locator 6 : Enter the “from” and “through” service data in this field in the MMDDYY format. If this is a single-day billing, enter the date in both the “from” and through “section.”
Form Locator 7 : NOT USED
Form Locator 8 : Enter the patient’s name (last, first, MI).
Form Locator 9 : Enter the patient’s mailing address (Street number/PO box, city, state, zip).
Form Locator 10 : Enter the patient’s date-of-birth.
Form Locator 11 : Enter the patient’s sex (M or F).
Form Locator 12 : Enter the date-of-admission or the date of care.
Form Locator 13 : Enter the time of admission in military time with 2 characters.
Form Locator 14 : Enter the 1-digit code indicating the priority of this visit.
Form Locator 15 : Enter the 1-digit code indicating the source of referral for this visit.
Form Locator 16 : Enter the time of discharge in military time with 2 characters.
Form Locator 17 : This is the discharge status line. Use the correct two-digit code from the NUBC manual.
Form Locator 18 – 28 : These are all condition codes. Again, use the NUBC manual to insert any applicable codes on these eleven lines.
Form Locator 29 : This is an accident code. You can use the NUBC to find the two-digit code relating to the accident.
Form Locator 30 : NOT USED
Form Locator 31 – 34 : These lines are for any occurrence codes and dates from the NUBC manual.
Form Locator 35 – 36 : These lines are for any occurrence span codes and dates (MMDDYY).
Form Locator 37 : NOT USED
Form Locator 38 : Enter the name and address of the individual or party responsible for the bill.
Form Locator 39 – 41 : These lines are for value codes and amounts for any special circumstances. Again, consult the NUBC manual.
Form Locator 42 : Enter the appropriate revenue code from the NUBC manual.
Form Locator 43 : Enter the revenue code description from the code above, Investigational Device Exemption (IDE) number, or Medicaid drug rebate NDC (National Drug Code).
Form Locator 44 : Enter the HCPCS (Healthcare Common Procedure Coding System), HIPPS (Health Insurance Prospective Payment System) rate codes, or any accommodation rates codes on this line.
Form Locator 45 : Enter the service dates (MM/DD/YY).
Form Locator 46 : Enter the number of service units (e.g., visits, days, etc.)
Form Locator 47 : Enter the total charges related to the NUBC manual code from field 42.
Form Locator 48 : Enter any non-covered charge related to the NUBC manual code from field 42.
Form Locator 49 : NOT USED
Form Locator 50 : Enter all payers names in order of their liability (e.g., primary, secondary, tertiary, etc.)
Form Locator 51 : Enter the Health Plan ID of any payers above.
Form Locator 52 : Enter the appropriate code to signify any release of information from the payer names on line 50.
Form Locator 53 : Enter the assignment of benefits from the payer names on line 50.
Form Locator 54 : Enter the amount of money (in dollars and cents) received toward the payment of this bill prior to submitting the form.
Form Locator 55 : Enter the estimated amount due.
Form Locator 56 : Enter the 10-digit National Provider ID.
Form Locator 57 : Enter the 7-digit number for other providers if required.
Form Locator 58 : Enter the insured’s name.
Form Locator 59 : Enter the patient’s relationship to the insured.
Form Locator 60 : Enter the insured’s unique identifier (16-digit ID)
Form Locator 61 : Enter the insured’s group name.
Form Locator 62 : Enter the insured’s group number.
Form Locator 63 : Enter the treatment authorization code.
Form Locator 64 : Enter the document control number (a.k.a the internal control number)
Form Locator 65 : Enter the employer’s name.
Form Locator 66 : Enter the Dx and Procedure Code Qualifier.
Form Locator 67 : Enter the ICD-9-CM diagnosis code and POA indicators.
Form Locator 68 : NOT USED
Form Locator 69 : Enter the ICD-9-CM diagnosis or reason for the visit.
Form Locator 70 : Enter the patient’s reason for visit codes.
Form Locator 71 : NOT USED
Form Locator 72 : Enter the ICD-9-CM code for the external cause of injury.
Form Locator 73 : NOT USED
Form Locator 74 : Enter other procedure code and date in this line.
Form Locator 75 : NOT USED
Form Locator 76 : Enter the attending provider’s name and identifiers
Form Locator 77 : Enter the operating physician’s ID.
Form Locator 78 – 79 : Enter other provider’s names and identifiers.
Form Locator 80 : Enter any special remarks.
Form Locator 81 : Enter any additional codes relating to another Form Locator overflow.
With a thorough understanding of the requirements, you and your billing team can efficiently manage these forms and work towards smoother medical claims billing and processing. Logik is an industry expert with insight to help you with the entire billing process , improve your claim rate, and increase your revenue collection. We help you explore new alternatives to advance workflows and productivity. If you are looking to spend less time dealing with paperwork and more on treating your patients, Logik can help. Contact us to learn how we can streamline your billing process today.
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This form, also known as the UB-04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. Because it serves many payers, a particular payer may not need some data elements. The National Uniform Billing Committee (NUBC) maintains lists of approved coding for the form. Medicare Administrative
On your institutional claim, you will need to notate that you either have (Y) a signed assignment of benefits from the patient permitting direct payment from the payer to the provider, (N) if there is no signed assignment of benefits on file which will direct the payer to send payment to the patient, or (W) if a signed assignment of benefits is …
Medica follows national and state uniform billing guidelines for the submission of UB-04 claim forms, although some fields required by Medicare or other payers may not be necessary for Medica claims. Inside is a blank UB-04 claim form for reference, and information on Medica’s requirements for successful completion of the UB-04 claim form.
53. Assignment of Benefits Enter "Y" for yes. 54. Prior Payments Enter the amounts paid by the other insurance payers listed in form locator 50. If payment is made by other insurance, proof of payment (e.g., EOB) must be attached to the claim form. 55. Estimated Amount Due The amount estimated to be due.
The UB-04 is for healthcare systems, and CMS-1500 is for individual providers. In other words, if you work in a behavioral healthcare practice or clinic setting, you will use the UB-04. If you are a physician or a doctor, you should use the CMS-1500 claim form to complete your billing. Breaking Down the Fields of the UB-04 Form