Form Preview Example

new UB-04 FoRm & instRuctions

The Ofice of Management and Budget (OMB) and the National Uniform Billing Committee (NUBC) previously approved the UB-04 claim form, also known as the CMS-1450 form.The UB-04 claim form accommodates the National Provider Identiier (NPI) and incorporated other important changes.This form replaced the UB-92 claim form and was phased in over a transition period beginning March 1, 2007.The UB-04 form has been used exclusively for institutional billing beginning May 23, 2007. Sample UB-04 forms for inpatient and outpatient services are enclosed.

THE UB-04 CLAIM FORM AND NPI

The UB-04 claim form includes several ields that accommodate the use of your NPI. Although the form accommodates the NPI, you must continue to report your current provider identiication numbers in the appropriate areas of the form.

UB-04 Data FielD RequiRements

FIELD LOCATION	DESCRIPTION	INPATIENT	OUTPATIENT
UB-04	DESCRIPTION	INPATIENT	OUTPATIENT
UB-04

1	Provider Name and Address	Required	Required
2	Pay-To Name and Address	Situational	Situational
3a	Patient Control Number	Required	Required
3b	Medical Record Number	Required	Required

4	Type of Bill	Required	Required

5	Federal Tax Number	Required	Required
6	Statement Covers Period	Required	Required
7	Future Use	N/A	N/A
8a	Patient ID	Situational	Situational

8b	Patient Name	Required	Required

9	Patient Address	Required	Required
10	Patient Birthdate	Required	Required
11	Patient Sex	Required	Required
12	Admission Date	Required	Required

13	Admission Hour	Required	Required

14	Type of Admission/Visit	Required	N/A
15	Source of Admission	Required	Required
16	Discharge Hour	Required	Required
17	Patient Discharge Status	Required	Required

18-28	Condition Codes	Required if Applicable	Required if Applicable

29	Accident State	Situational	Situational
30	Future Use	N/A	N/A
31-34	Occurrence Code and Dates	Required if Applicable	Required if Applicable
35-36	Occurrence Span Codes and Dates	Required if Applicable	Required if Applicable

37	Future Use	N/A	N/A

38	Subscriber Name and Address	Required	Required
39-41	Value Codes and Amounts	Required if Applicable	Required if Applicable
42	Revenue Code	Required	Required
43	Revenue Code Description	Required	Required

44	HCPCS/Rates	Required if Applicable	Required if Applicable

*For additional information on the completion of ields, please refer to the NUBC Oficial UB-04 Data Speciications Manual.

FIELD LOCATION	DESCRIPTION	INPATIENT	OUTPATIENT
UB-04	DESCRIPTION	INPATIENT	OUTPATIENT
UB-04

45	Service Date	N/A	Required

46	Units of Service	Required	Required

47	Total Charges (By Rev. Code)	Required	Required
48	Non-Covered Charges	Required if Applicable	Required if Applicable
49	Future Use	N/A	N/A
50	Payer Identiication (Name)	Required	Required
51	NPI	Required	Required

52	Release of Info Certiication	Required	Required
53	Assignment of Beneit Certiication	Required	Required
54	Prior Payments	Required if Applicable	Required if Applicable
55	Estimated Amount Due	Required	Required

56	NPI	Required	Required

57	Health Plan IDs	Required	Required
58	Insured’s Name	Required	Required
59	Patient’s Relation to the Insured	Required	Required
60	Insured’s Unique ID	Required	Required
61	Insured Group Name	Situational	Situational

62	Insured Group Number	Situational	Situational
63	Treatment Authorization Codes	Required if Applicable	Required if Applicable
64	Document Control Number	Situational	Situational
65	Employer Name	Situational	Situational

66	Diagnosis/Procedure Code Qualiier	Required	Required
67	Principal Diagnosis Code/Other Diagnosis Codes	Required	Required
68	Future Use	N/A	N/A
69	Admitting Diagnosis Code	Required	Required if Applicable
70	Patient’s Reason for Visit Code	Situational	Situational
71	PPS Code	Situational	Situational

72	External Cause of Injury Code	Situational	Situational
73	Future Use	N/A	N/A
74	Principal Procedure Code/Date	Required if Applicable	Required if Applicable
75	Future Use	N/A	N/A

76	Attending Name/ ID-Qualiier	Required	Required
77	Operating ID	Situational	Situational
78-79	Other ID	Situational	Situational
80	Remarks	Situational	Situational
81	Code-Code Field/Qualiiers
	*0-A0	N/A	N/A

	*A1-A4	Situational	Situational
	*A5-B0	N/A	N/A
	*B1-B2	Situational	Situational
	*B3	Required	Required

*For additional information on the completion of ields, please refer to the NUBC Oficial UB-04 Data Speciications Manual.

We would also like to remind you of the requirements for electronic transactions. As a reminder, Passport Health Plan strongly recommends the continued use of plan identiication numbers in addition to NPI.

837 I Data FielD RequiRements

LOOP ID

2000A

LOOP ID

2010AA

LOOP ID

2010AA

====================== 837 I ====================== BILLING TAXONOMY LOOP ======================

Loop Name	Segment Name	PRV01 Qualiier	PRV02 Qualiier	PRV03 Value
Billing/Pay-To Provider Specialty Information	PRV	BI	ZZ	= Taxonomy
Billing/Pay-To Provider Specialty Information	PRV	PT	ZZ	= Taxonomy
		PT
====================== 837 I ====================== BILLING PROVIDER LOOP ======================


Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
			24	= TAX ID
Billing Provider	NM1	85	34	= SSN
			XX	= NPI
Loop Name	Segment Name	REF01 Qualiier		REF02 Value


		SY		= SSN
Billing Provider Secondary Identiication	REF	EI		= TAX ID
		1D		= MAID

LOOP ID

2010AB

LOOP ID

2010AB

LOOP ID

2310A

LOOP ID

2310A

LOOP ID

2310E

LOOP ID

2310E

====================== 837 I ====================== PAY TO PROVIDER LOOP ======================

Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
			24	= TAX ID
Pay-To-Provider	NM1	87	34	= SSN
			XX	= NPI
Loop Name	Segment Name	REF01 Qualiier		REF02 Value


		SY
Pay-To-Provider Secondary Identiication	REF	EI
		1D

====================== 837 I ====================== ATTENDING PROVIDER LOOP ======================

Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
			24	= TAX ID
Attending Physician	NM1	82	34	= SSN
			XX	= NPI


Loop Name	Segment Name	REF01 Qualiier		REF02 Value
Attending Physician Secondary Identiication	REF	N5		= Facets ID
====================== 837 I ====================== SERVICE FACILITY LOOP ======================

Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
			24	= TAX ID
Service Facility Location	NM1	82	34	= SSN
			XX	= NPI


Loop Name	Segment Name	REF01 Qualiier		REF02 Value
Service Facility Location Secondary Identiication	REF	N5		= Facets ID

Please let us know if you have any questions regarding these instructions. In addition, if you have any questions regarding the NPI, the application process, or reporting your NPIs to us, please contact your Provider Relations representative.

samPle INPATIENT UB-04 FoRm

3a PAT.

4 TYPE

CNTL #

OF BILL

b. MED.

REC. #

5 FED. TAX NO.

STATEMENT COVERS PERIOD

FROM

THR OUGH

8 PATIENT NAME	a						9 PATIENT ADDRESS			a
b							b											c	d	e
10 BIRTHDATE	11 SEX			ADMISSION		16 DHR	17 STAT					CONDITION CODES							29 ACDT 30
10 BIRTHDATE	11 SEX	12	DATE	13 HR 14 TYPE	15 SRC	16 DHR	17 STAT	18	19	20	21	22	23	24	25	26	27	28	STATE
		12	DATE	13 HR 14 TYPE	15 SRC			18	19	20	21	22	23	24	25	26	27	28	STATE

OCCURRENCE

OCCURRENCE SPAN

CODE

DATE

CODE

DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE

FROM

THROUGH

VALUE CODES

CODE

AMOUNT

CODE

AMOUNT

CODE

AMOUNT

44 HCPCS / RATE / HIPPS CODE

42 REV. CD.

43 DESCRIPTION

45 SERV. DATE

46 SERV. UNITS

47 TOTAL CHARGES

48 NON-COVERED CHARGES 49

PAGE

CREATION DATE

TOTALS

50 PAYER NAME

52 REL.

53 ASG.

51 HEALTH PLAN ID

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56 NPI

INFO

BEN.

OTHER

PRV ID

58 INSURED’S NAME

59 P. REL

60 INSURED’S UNIQUE ID

61 GROUP NAME

62 INSURANCE GROUP NO.

63 TREATMENT AUTHORIZATION CODES

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

71 PPS

69 ADMIT

70 PATIENT

REASON DX

CODE

ECI

PRINCIPAL PROCEDURE

OTHER PROCEDURE

76 ATTENDING

NPI

QUAL

CODE

DATE

CODE

DATE

CODE

DATE

LAST

FIRST

OTHER PROCEDURE

77 OPERATING

NPI

QUAL

CODE

DATE

CODE

DATE

CODE

DATE

LAST

FIRST

81CC

80 REMARKS

78 OTHER

NPI

QUAL

LAST

FIRST

QUAL

79 OTHER

NPI

LAST

FIRST

UB-04 CMS-1450

APPROVED OMB NO.

NUBC

™ National Uniform

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

Billing Committee LIC9213257

Green = Required/Preferred

Black = situational/Required if applicable/Reserved

samPle OUTPATIENT UB-04 FoRm

3a PAT.

4 TYPE

CNTL #

OF BILL

b. MED.

REC. #

5 FED. TAX NO.

STATEMENT COVERS PERIOD

FROM

THR OUGH

8 PATIENT NAME	a						9 PATIENT ADDRESS			a
b							b											c	d	e
10 BIRTHDATE	11 SEX			ADMISSION		16 DHR	17 STAT					CONDITION CODES							29 ACDT 30
10 BIRTHDATE	11 SEX	12	DATE	13 HR 14 TYPE	15 SRC	16 DHR	17 STAT	18	19	20	21	22	23	24	25	26	27	28	STATE
		12	DATE	13 HR 14 TYPE	15 SRC			18	19	20	21	22	23	24	25	26	27	28	STATE

OCCURRENCE

OCCURRENCE SPAN

CODE

DATE

CODE

DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE

FROM

THROUGH

VALUE CODES

CODE

AMOUNT

CODE

AMOUNT

CODE

AMOUNT

44 HCPCS / RATE / HIPPS CODE

42 REV. CD.

43 DESCRIPTION

45 SERV. DATE

46 SERV. UNITS

47 TOTAL CHARGES

48 NON-COVERED CHARGES 49

PAGE

CREATION DATE

TOTALS

50 PAYER NAME

52 REL.

53 ASG.

51 HEALTH PLAN ID

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56 NPI

INFO

BEN.

OTHER

PRV ID

58 INSURED’S NAME

59 P. REL

60 INSURED’S UNIQUE ID

61 GROUP NAME

62 INSURANCE GROUP NO.

63 TREATMENT AUTHORIZATION CODES

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

71 PPS

69 ADMIT

70 PATIENT

REASON DX

CODE

ECI

PRINCIPAL PROCEDURE

OTHER PROCEDURE

76 ATTENDING

NPI

QUAL

CODE

DATE

CODE

DATE

CODE

DATE

LAST

FIRST

OTHER PROCEDURE

77 OPERATING

NPI

QUAL

CODE

DATE

CODE

DATE

CODE

DATE

LAST

FIRST

81CC

80 REMARKS

78 OTHER

NPI

QUAL

LAST

FIRST

QUAL

79 OTHER

NPI

LAST

FIRST

UB-04 CMS-1450

APPROVED OMB NO.

NUBC

™ National Uniform

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

Billing Committee LIC9213257

Green = Required/Preferred

Black = situational/Required if applicable/Reserved

Question	Answer
Form Name	04 Form Printable
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	aia product substitution request form, 04 form, ub 04 insurance form, printable ub 04 claim form

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