Ub 94 Form – Fill Out and Use This PDF

1

Billing Provider Information

Required

Four-lines of information:

Name

NOTE: This is the physical

Address

address of the location where

City/State/Zip

services were provided. This is

Phone: 123-123-1234

not a Post Office Box address.

2

Pay-To Provider Information

Situational

Required if the pay-to

provider address is different

NOTE: A PO Box is acceptable

than the billing provider.

in this space.

3a

Patient Control Number

Optional

Enter your patient account

number, if provided this

number will be returned on

the EOB/EOP.

3b

Medical/Health Record Number

Optional

May be used for the patient’s

medical record number. This

field is not reported back on

the EOB/EOP.

4

Bill Type

Required

Use NUBC taxonomy tables

for acceptable values

NOTE: This field plays a role

in the adjudication of the

claim. An incorrect value in

this field could result in an

incorrect payment.

5

Federal Tax ID

Required

Enter number WITHOUT

hyphen: NNNNNNNNN

NOTE: Forms are scanned

into electronic files; a hyphen

may result in payment

inaccuracy or rejection of

your claim.

6

Statement Covers From and

Required

Outpatient = enter the first

Thru Dates

and last dates of services

billed on this claim.

FORMAT: MMDDYY without

Inpatient = enter admit and

dashes, slashes or spaces.

discharge date for this

admission. If interim billing

is being performed, enter the

first and last dates of the

services that are being billed

on the form.

7

Unassigned

Not Used

8a

Patient ID#

Required

Enter patient’s DCHP ID#:

STAR: 9 numeric characters

CHIP: 9 alpha-numeric

characters with alpha

Page 1 of 9

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

character appearing in the lead

position.

8b

Patient Name

Required

Patient name:

Last, First Middle

Sample: SMITH, MARY JO

9a

Patient Address

Required

Patient’s street address

9b

Patient City

Required

Patient’s city

9c

Patient State

Required

Patient’s state – 2-digit USPO

abbreviation required

9d

Patient Zip Code

Required

Patient’s zip code – 5 digits

are required. 9-digit is

optional. If 9-digit is used

DO NOT use a hyphen.

9e

Patient County Code

Optional

If used, must use codes

provided by American

National Standards Institute in

ISO3166

10

Date of Birth

Required

Enter date: MMDDYYYY

without hyphens, slashes or

spaces

11

Sex

Required

M = male

F = female

U = unknown

12

Admission or Start of Care Date

Required on both inpatient

Enter date: MMDDYY

and outpatient claims

without hyphens, slashes or

spaces

13

Admission Hour

Required

Use NUBC taxonomy tables

for acceptable values: 00

through 23 to define the hour

14

Admission Type

Required on Inpatient

1 = emergency

2 = urgent

Optional on Outpatient

3 = elective

4 = newborn

5 = trauma

9 = information not available

15

Admission Source

Required

Use NUBC taxonomy tables

for acceptable values

16

Discharge Hour

Required on inpatient

Use NUBC taxonomy tables

where bill type end is a 1,

for acceptable values: 00

2, 3, or 4.

through 23 to define the hour

Optional on outpatient

17

Discharge Status

Required on inpatient

Use NUBC taxonomy tables

for acceptable values

Not Used on outpatient

18-28

Condition Codes

Situational, but required

Use NUBC taxonomy tables

where the condition code

for acceptable values

Page 2 of 9

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable

All CHIP and STAR claims

must indicate YES.

54

Prior Payments

Situational

Enter any dollar amount paid

by the payer on this claim

55

Estimated Amount Due

Not Required

56

NPI

Required

The 10-digit NPI number of

the BILLING PROVIDER

identified in field 1 on the

UB04

57

Other Billing Provider

Not Required

58

Insured Name

Required

Name of the insured person

for the insurance shown in

field 50.

For STAR and CHIP this will

always be the PATIENT.

59

Insured Relationship to Patient

Required

Use NUBC taxonomy tables

for acceptable values

For STAR and CHIP this will

always = 18

60

Insured’s Unique ID

Required

Insurance ID# assigned by the

health plan of payer to the

insured person

CHIP: 9-character numbers

starting with a alpha character

and followed by 8 numeric

characters

STAR: 9-numeric characters

61

Group Name

Required for other

Enter the name of group,

insurance

which is will usually be the

employer through which the

Not Required for STAR

insurance is received.

and CHIP

For STAR and CHIP, this

field can be left blank or can

be populated with “DCHP”.

62

Insurance Group Number

Required for other

Enter the group ID# assigned

insurance

by the applicable payer.

Not Required for STAR

For STAR and CHIP this field

and CHIP

can be left blank.

63

Treatment Authorization Codes

Situational

If prior authorization code

was given for the services

represented in the claim, enter

than number in this space.

64

Document Control Number

Situational

If re-submitting a claim that

was previously adjudicated,

Page 5 of 9

Version 1.1 dated 5-27-07

Required = Mandatory

Optional = used at discretion of provider

Preferred = if available, please provide

Situational = required when applicable