How the UB-04 Form Is Used to Bill Insurance Companies

The UB-04 is the standard claim form that institutional providers, such as hospitals, use to bill Medicare, Medicaid, and other health insurance companies for services. Knowing how to use each field of the UB-04 form can help to streamline the process, minimize errors and delays, and ensure prompt and accurate payment.

Who Can Bill Claims Using the UB-04?

Any institutional provider can use the UB-04 for billing medical claims. Non-institutional providers or suppliers, such as physicians or providers of durable medical equipment, use the CMS-1500 form.

Institutional providers that can use the UB-04 form include:

• Community mental health centers that provide therapy and psychological services
• Comprehensive outpatient rehabilitation facilities (physical and occupational therapy)
• Critical access hospitals, typically small facilities with limited services
• End-stage renal disease facilities that offer dialysis care
• Federally qualified health centers that provide community services, regardless of patient ability to pay
• Histocompatibility laboratories (labs specializing in organ transplant testing)
• Home health agencies
• Hospice facilities for end-of-life care
• Hospitals providing comprehensive medical services
• Indian Health Services facilities (serving Native American populations)
• Organ procurement organizations that manage organ donation and transplant
• Outpatient physical therapy services
• Occupational therapy services
• Speech pathology services
• Religious non-medical healthcare institutions
• Rural health clinics, providing primary care in rural settings
• Skilled nursing facilities for extensive rehabilitation and other services

Tips for Accurately Preparing the UB-04

To fill out the form accurately and completely:

• Verify required data by checking with each insurance payer.
• Ensure accuracy by entering all data correctly in the specified fields.
• Include the patient’s name exactly as it appears on the insurance card.
• Choose correct diagnosis codes (​ICD-10 or ICD-11) 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.

Understanding Each Field on the UB-04 Form

The UB-04 has 81 fields, known as form locators (FL), each with a specific purpose:

• FL 1: Billing provider information including name, address, and phone number
• FL 2: Pay-to provider’s name and address, if different
• FL 3: Patient control and medical record numbers
• FL 4: Type of bill (TOB). This is a four-digit code beginning with zero, according to the National Uniform Billing Committee guidelines.
• FL 5: Federal tax number for your facility
• FL 6: Statement from and through dates for the service covered on the claim, in MMDDYY (month, date, year) format
• FL 7: Number of administratively necessary days
• FL 8: Patient name in Last, First, MI format
• FL 9: Patient’s address and contact details
• FL 10: Patient birthdate in MMDDCCYY (month, day, century, year) format
• FL 11: Patient sex (M, F, or U)
• FL 12: Admission date in MMDDCCYY format
• FL 13: Admission hour using a two-digit code from 00 for midnight to 23 for 11 p.m.
• FL 14: Type of visit: 1 for emergency, 2 for urgent, 3 for elective, 4 for newborn, 5 for trauma, 9 for information not available
• FL 15: Point of origin (source of admission) 
• FL 16: Discharge hour in the same format as line 13
• FL 17: Discharge status using the NUBC manual codes
• FL 18-28: Condition codes using the two-digit codes from the NUBC manual for up to 11 occurrences
• FL 29: Accident state (if applicable) using a two-digit state code
• FL 30: Accident date
• FL 31-34: Occurrence codes and dates using the NUBC manual for codes
• FL 35-36: Occurrence span codes and dates in MMDDYY format
• FL 37: Not in use
• FL 38: Responsible party name and address
• FL 39-41: Value codes and amounts for special circumstances from the NUBC manual
• FL 42: Revenue codes from the NUBC manual
• FL 43: Revenue code description, investigational device exemption (IDE) number, or Medicaid drug rebate NDC (national drug code)
• FL 44: HCPCS Healthcare Common Procedure Coding System), accommodation rates, HIPPS (health insurance prospective payment system) rate codes
• FL 45: Service dates
• FL 46: Service units
• FL 47: Total charges
• FL 48: Non-covered charges
• FL 49: Page_of_ and Creation date
• FL 50: Payer Identification (a) Primary (b) Secondary and (c) Tertiary
• FL 51: Health plan ID (a) Primary (b) Secondary and (c) Tertiary
• FL 52: Release of information (a) Primary (b) Secondary and (c) Tertiary
• FL 53: Assignment of benefits (a) Primary (b) Secondary and (c) Tertiary
• FL 54: Prior payments (a) Primary (b) Secondary and (c) Tertiary
• FL 55: Estimated amount due (a) Primary (b) Secondary and (c) Tertiary
• FL 56: Billing provider national provider identifier (NPI)
• FL 57: Other provider ID (a) Primary (b) Secondary and (c) Tertiary
• FL 58: Insured’s name (a) Primary (b) Secondary and (c) Tertiary
• FL 59: Patient’s relationship (a) Primary (b) Secondary and (c) Tertiary
• FL 60: Insured’s unique ID (a) Primary (b) Secondary and (c) Tertiary
• FL 61: Insurance group name (a) Primary (b) Secondary and (c) Tertiary
• FL 62: Insurance group number (a) Primary (b) Secondary and (c) Tertiary
• FL 63: Treatment authorization code (a) Primary (b) Secondary and (c) Tertiary
• FL 64: Document control number also referred to as Internal control number (a) Primary (b) Secondary and (c) Tertiary
• FL 65: Insured’s employer name (a) Primary (b) Secondary and (c) Tertiary
• FL 66: Diagnosis codes (ICD)
• FL 67: Principle diagnosis code, other diagnosis, and present on admission (POA) indicators
• FL 68: Not in use
• FL 69: Admitting diagnosis codes
• FL 70: Patient reason for visit codes
• FL 71: Prospective payment system (PPS) code
• FL 72: External cause of injury code and POA indicator
• FL 73: Not in use
• FL 74: Other procedure code and date
• FL 75: Not in use
• FL 76: Attending provider NPI, ID, qualifiers, and last and first name
• FL 77: Operating physician NPI, ID, qualifiers, and last and first name
• FL 78: Other provider NPI, ID, qualifiers, and last and first name
• FL 79: Other provider NPI, ID, qualifiers, and last and first name
• FL 80: Remarks
• FL 81: Taxonomy code and qualifier

The National Uniform Billing Committee, the governing body for medical claims billing forms, is responsible for the design and printing of the UB-04 form.