Tips for Completing the UB-04 (CMS-1450) Form

This billing guide is designed to assist with the completion of the UB-04 (CMS-1450) claim 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. Although developed by the Centers for Medicare and Medicaid (CMS), the form has become the standard form used by all insurance carriers.

Billing Guide for UB-04 (CMS 1450) Claim Form

Follow these tips to help ensure proper scanning and timely processing:
KEY:
R = Required | RA = Required if applicable | NR = Not Required | O = Optional
Field ID Field Description Data Type Instructions
01 Billing provider name, address and telephone number (phone # and fax # desirable) R The name and service location of the provider submitting the bill. Enter information in this format:
Line 1: Provider Name
Line 2: Street Address
Line 3: City, State, ZIP code. (Use standard state abbreviation and valid ZIP code).
Line 4: Telephone; Fax; Country Code
02 Pay-to name and address NR Enter the address that the provider submitting the bill intends payment to be sent if different than FL 01.
Line 1: Pay-to Name
Line 2: Street Address or Post Office Box
Line 3: City, State, and 5-digit Zip Code
Line 4: NOT USED. Reserved for Assignment by the NUBC
03a Patient control number O Enter patient’s unique (alphanumeric) number assigned by provider to retrieve individual accounts. Left-justify up to 24 characters.
03b Medical/health record number NR Enter the number assigned to the patient’s medical/health record by the provider. Left-justify up to 24 characters.
04 Type of Bill (Specific codes required. Refer to UB-04 manual) R Enter the 4-digit code to indicate the specific type of bill (e.g., hospital inpatient, outpatient, replacements, voids, etc.). The first digit is a leading zero, The next 2 digits indicate the type of bill, The fourth digit indicates the frequency of the bill. Type of bill must be consistent with services rendered.
05 Federal tax number R Enter the number assigned to the provider by the federal government for tax reporting purposes. Left-justify up to 10 characters (include hyphen).
06 Statement covers period R Enter the beginning and ending service dates of the entire period covered in the claim in MMDDYY format. For services provided on a single day, enter the date of service as both the “from” and “through” date.
07 INSURED’S ADDRESS/TELEPHONE NUMBER NR Reserved for Assignment by the NUBC.
08a Patient name – identifier R The patient identifier as assigned by the payer. Report if number is different from the subscriber/insured’s ID.
08b Patient's Name R Enter patient’s last name, first name, and middle initial.
09
a-e
Patient Address R Enter patient’s complete mailing address including street number and name or P.O. box or RFD; city; state; ZIP code.
10 Patient's Birthdate R Enter patient’s date of birth in MMDDYYYY format.
11 Patient's Sex R Enter M for male or F for female.
12 Admission/start of care date R Enter the date of admission for inpatient services; for other services enter the date the episode of care began. Enter in MMDDYY format.
13 Admission Hour RA Enter the hour of admission or start of care in military time using 2 numeric characters.
14 Priority (type) of visit RA Enter the 1-digit code indicating the priority of this admission/visit.
15 Source of referral for admission or visit RA Enter the 1-digit code indicating the source of referral for this admission or visit.
16 Discharge Hour RA Enter the hour of discharge from inpatient care in military time using 2 numeric characters.
17 Patient discharge status RA Enter the code indicating the disposition or discharge status of the patient on the ending service date of the period covered on this bill, as reported in FL6.
Note: Completion of this field is not required on rural health clinic (RHC) and federally qualified health center (FQHC) claims.
18 - 28 Condition Codes RA Used to identify conditions or events relating to this bill that may affect processing.
29 Accident State NR Enter the 2-digit state abbreviation indicating where the accident occurred.
30 Unlabeled NR Reserved for assignment by the NUBC.
31 - 34 Occurrence codes and dates RA Enter the code and associated date noting a significant event relating to the claim that may affect payer processing.
35 - 36 Occurrence span codes and dates NR A code and the related dates that identify an event relating to the payment of the claim.
37 Unlabeled NR Reserved for assignment by the NUBC.
38 Responsible Party Name and Address R Enter the name and address of the party responsible for the bill. Left-justify and enter up to 5 lines of information.
39 - 41 Value Code/Amount RA If required by Medica contract, enter value code 01 and the semiprivate room rate for the facility.
42 Revenue Code R Enter the appropriate numeric code to identify specific accommodations and/or ancillary service in ascending numeric order, by date of service if applicable. Revenue code 0001 must be the final entry on all bills.
43 Revenue Description R Enter the narrative description of the related room and board and/or ancillary categories shown in field 42. The 23rd line contains an incrementing page number and total pages for the claim on each page, creation date of the claim on each page and a claim total for covered and non-covered charges on the final claim page only indicated with a Revenue Code of “0001”.
44 HCPCS/Rate/HCPCS Code RA Enter the accommodation rate for room and board on inpatient claims, or the appropriate CPT®/HCPCS code for the outpatient ancillary service being reported. Important: Refer to your Medica contract to determine whether a CPT/HCPCS code is required for adjudication of the claim. For example, outpatient surgeries being paid under a grouper or other codes (e.g., labs, therapies) carved out for specific rates.
45 Service Date RA Enter the date on which the indicated service was performed—Use MMDDYY format. The date must be entered on outpatient series claims where the “from” and “through” dates are not the same (e.g., for physical, occupational and speech therapies).
46 Service Units R Enter the total number of accommodation days, ancillary units of service or visits as appropriate.
47 Total Charges R Enter the total charge related to the revenue code subcategory listed in field 42. Indicate the total charge of the claim on the last line with corresponding 0001 revenue code.
48 Non-Covered Charges NR Enter the total charge related to the revenue code subcategory listed in field 42. Indicate the total charge of the claim on the last line with corresponding 0001 revenue code.
49 Unlabeled NR Reserved for future use by the NUBC.
50 Payer Name R Enter all payers in order of their liability, from whom some payment may be received for this claim. Enter the appropriate source of payment alpha code for each.
51 Health Plan ID NR New field, not being used by all insurance providers
52 Release of Information R Enter the appropriate code indicating whether there is a signed statement from the member on file permitting the provider to release data to other organizations to adjudicate the claim.
53 Assignment of Benefits R Enter the appropriate code indicating whether there is a signed form on file authorizing Medica to pay the provider directly for services.
54 Prior Payments RA Enter the amount, in dollars and cents, received toward payment of this bill prior to billing the insurance provider.
55 Estimated Amount Due O In dollars and cents, enter the estimated amount due from Medica after prior payments are subtracted.
56 National Provider ID RA Enter the 10-digit National Provider Identifier.
57 Other Provider ID RA Enter the correct 7-digit provider number as assigned by the insurance provider for the type of services provided.
58 Insured's Name R Enter the name of the individual on the insurance policy.
59 Patient’s Relationship to Insured R Enter the 2-digit code indicating the relationship of the patient to the insured.
60 Insured’s Unique Identifier R Enter and left-justify the insured’s 16-digit ID number assigned by their insurance provider.
61 Insured’s Group Name RA If applicable, enter only if group coverage applies.
62 Insured’s Group Number RA Enter and left-justify the 5-digit or 6-digit policy number if group coverage applies.
63 Treatment Authorization Code RA Used to indicate that a payer has authorized treatment.
64 Document Control Number O Enter the number assigned to the original claim by Medica when submitting an adjusted claim. Left-justify up to 26 alphanumeric characters.
65 Employer Name NR If employed, please state the employer's company name.
66 Dx and Procedure Code Qualifier NR  
67 Principal Dx Code and Present on Admission Indicator R Enter the complete ICD-9-CM diagnosis code that describes the principal diagnosis or the chief reason for performing a service on an outpatient basis.
67
a - q
Other Dx Codes R Enter the complete ICD-9-CM diagnosis codes for up to 17 additional conditions.
68 Unlabeled NR Reserved for Assignment by the NUBC.
69 Admitting Diagnosis R The ICD-9-CM diagnosis code that describes the patient’s diagnosis or reason for visit at the time of inpatient admission.
70
a - c
Patient’s Reason for Visit RA Patient’s reason for visit at the time of outpatient registration.
71 Prospective Payment System Code RA Not used by many insurancer providers.
72 External Cause of Injury Code RA Enter the complete ICD-9-CM code for the external cause of injury, poisoning or adverse effect. Note: Per the “ICD-9-CM Official Guidelines for Coding and Reporting,” E-codes should only be assigned to the initial treatment of an injury, poisoning, or adverse effect of drugs. A late effect E-code may be used for subsequent visits when a late effect of the initial injury or poisoning is being treated. For further information regarding E-codes please refer to the “ICD-9-CM Official Guidelines for Coding and Reporting,” which may be accessed at www.cdc.gov/nchs.
73 Unlabeled NR Reserved for Assignment by the NUBC.
74 Principal Procedure Code/Date RA The ICD-9-CM code for the principal procedure and date performed.
74
a - e
Other Procedure Code/Date RA The ICD-9-CM procedure codes and dates for up to 5 additional procedures.
75 Unlabeled NR Reserved for Assignment by the NUBC.
76 Attending Provider Name and Identifiers R Enter the 10-digit NPI, 7-digit Medica-assigned provider (or UPIN) number and name of the attending or referring provider.
77 Operating Physician Name and Identifiers RA Used to enter the operating physician’s ID. Required if there is a surgical procedure code listed on the claim.
78 - 79 Other Provider Names and Identifiers RA Used to enter the other physician, assisting physician, referring physician or ordering provider ID.
80 Remarks RA Enter any special notations that may be helpful in adjudicating the claim. Remarks must be typewritten. (Note: If NPI is required, a taxonomy code is required.)
81
a - e
Code – Code Field RA Enter additional codes relating to another Form Locator overflow. Taxonomy Codes.

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