What is UB-04 Form? with Field Descriptions and Used Settings

Decoding Healthcare Billing: Explore the UB-04 Form – Unveiling Field Descriptions and Optimal Settings for Seamless Financial Precision!

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What is the UB-04 Form?

Simply UB-04 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 medical 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:

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The American Hospital Association

The American Hospital Association (AHA) is a professional group that raises awareness, fairness, and quality among health care 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?

The UB-04 form’s adaptability enables a wide range of healthcare organizations to efficiently bill claims. This standardized form is helpful to hospitals, assisted living facilities, and rehabilitation centers, among others, in providing insurance providers with important information. Its widespread use in the healthcare industry demonstrates how universally useful it is.

Structure of UB-04 Form: Navigating the Essentials

Patient Information: The patient information section is the central component of the UB-04 form, serving as a fundamental component that gathers important data. This area guarantees a thorough overview of the patient’s profile, from insurance details to demographic data, enabling precise invoicing and minimizing inconsistencies.

Provider Details: The part on provider details is crucial for healthcare professionals. It outlines the medical facility’s particulars, such as its name, address, and special identification numbers. Accuracy in this area not only speeds up invoicing procedures but also creates a unique identity for easy communication with insurance companies.

Type of Bill: The type of bill section of the UB-04 form is like a lighthouse, directing the billing procedure precisely. For clear and error-free communications with payers, precisely classifying the type of bill—whether it’s an initial claim, a resubmission, or a voided transaction—is essential.

Condition Codes: Condition codes are vital to the complex game of healthcare billing because they provide claims context. These codes provide insurers with a more detailed view by shedding light on particular situations related to a patient’s treatment. This section’s precise coding reduces the possibility of disagreements while also speeding up the processing of claims.

Occurrence Codes: By tracing the sequence of a patient’s medical history, the occurrence codes portion serves as a record. This part offers a timeline that improves the transparency of claims, starting with the admission date and continuing through important events during the stay. Here, precise code is equivalent to a well-written story that appeals to insurance companies.

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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. This form provides some essential improvements from the UB-92 form. 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 #’s
  • 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.

Zee Medical Billing guides you on what every FL requires, so you can fill out your UB-04 efficiently.

  • 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 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 providers NPI, ID, qualifiers, and last and first name.
  • Form Locator 79: Other providers 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, Zee Medical Billing recommends sending in the original form with the “red ink,” and keeping the photocopy for yourself. Occasionally, if you mail in a form it may not scan into their system properly and may delay, mishandle, or denial in 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, like Zee Medical Billing.
The UB-04 form may seem intimidating, but Zee Medical Billing is here to help you. Our dedicated staff is here for you with our user-friendly guide. We generally submit what is only required, with listed statements and invoices for medical services. If the insurance company asks for more medical information such as medical history, medical records, primary payer explanation of benefits, or proof of the accident, and injury or treatment.

Frequently Asked Questions

The UB-04 form, also known as the CMS-1450 form, is the standard billing form used by healthcare facilities to submit claims for reimbursement of services provided to patients. It is used for institutional billing, such as hospitals, skilled nursing facilities, and outpatient facilities.

The UB-04 form consists of various fields that capture essential information for billing and reimbursement purposes. Some common field descriptions include patient name, medical record number, admission date, discharge date, principal diagnosis, procedure codes, revenue codes, and the total charges for services provided.

When filling out the UB-04 form, there are certain settings that need to be considered. These settings include the appropriate National Provider Identifier (NPI) for the facility, accurate billing codes such as Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, revenue codes for each service rendered, and the correct billing frequency code.

The exact services or goods delivered to the patient are identified by revenue codes on the UB-04 form. Referring to the National Uniform Billing Committee (NUBC) official rules, which offer a comprehensive list of revenue codes and their related descriptions, will help you choose the correct revenue codes.

Zee Medical Billing offers comprehensive billing services and expertise in handling UB-04 form submissions. Our experienced team ensures accurate and timely completion of the form, adherence to billing guidelines, and maximized reimbursement for healthcare facilities. Contact our team to learn more about our services and how we can assist you with UB-04 form requirements.

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