Simply UB-04, also known as UB-92 or CMS-1450 form, can be used by any institutional provider for billing medical and mental health claims. The Centers for Medicare and Medicaid (CMS) created this uniform billing form to be used by institutional providers for claim billing. It has developed and grown into one of the most commonly used forms for billing and mental health claims. The UB-04 form is popular among all insurance carriers. Although a majority of these claims should be recorded electronically, the UB-04 is distinguished by white standard paper with red ink. This form is administered by two associations:
The American Hospital Association
The American Hospital Association (AHA) is a professional group that raises awareness, fairness, and quality among healthcare professionals and networks.
National Uniform Billing Committee
The National Uniform Billing Committee (NUBC) is a governing body that manages forms and codes for medical claims billing. Collectively, the AHA and NUBC design, modify, and update certain specifications for the UB-04 guidelines.
Who Can Bill Claim Using the UB-04?
Efficiency is a very important factor in the healthcare field. That’s why the UB-04 form is used by a range of healthcare companies to bill claims more efficiently. This standardized form helps hospitals, hospice providers, assisted living institutions, home health agencies, rehabilitation centers, and others to provide important information to insurance carriers. It is considered illegal if any entity fills out false information in the claim, and also impacts the reputation of healthcare providers as well as the revenue cycle management of practices.
What Is Different About The UB-04 Form?
The UB-04 form is the most contemporary version of the uniform bill used by institutional providers. Some of these changes comprise:
- Increased the number of condition code fields from seven to eleven fields
- Created a new ICD classifications field which can now be used in ICD 9 and 10
- Expansion of the diagnosis field sizes to accommodate ICD 10 codes
- Expand the number of fields for diagnoses from 9 to 18
- Revised physician fields to include specific fields for National Provider Identifier (NPI, first and last names, qualifications, and Tax ID)
- Addition of three specific fields for the patient’s purpose for the visit
Fields description of the UB-04 form
The UB-04 form has 81 fields and is referred to as form locators or “FL.” Each form locator has a distinctive purpose for the insurance carrier and provider so that they can communicate. To ensure a smooth process it’s important to fill out UB-04 fields correctly.
- 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 a 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 birth date 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 a two-digit code from 00 for midnight to 23 for 11 PM.
- Form Locator 14: Type of visit: 1 for an 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: 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 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 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 diagnoses, and present on-admission (POA) indicators.
- Form Locator 68: Not in use.
- Form Locator 69: Admitting diagnosis codes.
- Form Locator 70: Patient’s 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’s NPI, ID, qualifiers, and last and first name.
- Form Locator 79: Other provider’s NPI, ID, qualifiers, and last and first name.
- Form Locator 80: Remarks.
- Form Locator 81: Taxonomy code and qualifier.
After you double-check your form, the next step is to turn it in. To simplify the process, a majority of payers accept photocopied or black-and-white UB-04 medical claims. If you mail in your form then try to send in the original form with the “red ink,” and keep the photocopy for yourself. Occasionally, if you mail in a form, it may not scan into their system properly and may delay, mishandle, or deny payment. Sending the form electronically can make the process easier and give you peace of mind. Many large commercial payers now require these forms to be filed electronically directly from a provider or third-party billing agency.
