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

The UB-04 uniform medical billing form is the standard claim form that institutional providers use, such as hospitals and community mental health care centers. It is used to bill Medicare, Medicaid, and other health insurance companies for inpatient or outpatient services.

Although developed by the Centers for Medicare and Medicaid Services (CMS), the paper form has become the standard claim form used by all insurance carriers. The National United Billing Committee, the governing body for medical claims billing forms, is responsible for the design and printing of the UB-04 form.

This article explains who can fill out the form and what the form's various sections mean.

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
• Comprehensive outpatient rehabilitation facilities
• Critical access hospitals
• End-stage renal disease facilities
• Federally qualified health centers
• Histocompatibility laboratories
• Home health agencies
• Hospices
• Hospitals
• Indian Health Services facilities
• Organ procurement organizations
• Outpatient physical therapy services
• Occupational therapy services
• Speech pathology services
• Religious non-medical healthcare institutions
• Rural health clinics
• Skilled nursing facilities

How Is the UB-04 Form Different Than an Itemized Bill?

An itemized medical bill lists in detail all the services that were provided during a visit or stay—such as a blood test or physical therapy—and may be sent to the patient directly. The UB-O4 form is used by institutions to bill insurance companies.

Tips for Preparing the UB-04

To fill out the form accurately and completely:

• Check with each insurance payer to determine what data is required.
• Ensure that all data is entered accurately and in the correct fields.
• Enter insurance information, including the patient's name exactly as it appears on the insurance card.
• Use 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.

More detailed instructions can be found at www.cms.gov or www.nubc.org.

Fields of the UB-04

There are 81 fields or lines on a UB-04. They're referred to as form locators or "FL." Each form locator has a unique purpose:

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

Summary

Institutions use the UB-04 form to bill insurance for inpatient or outpatient medical and mental health claims. Examples include hospitals, hospices, rural health clinics, and comprehensive outpatient rehabilitation facilities. When filling out the form, be sure to understand the meaning of each of the 81 fields and to make sure that the information is accurate.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

1. National Uniform Billing Committee. National Uniform Billing Committee Official Data Specifications Manual.
2. National Uniform Billing Committee. National Uniform Billing Committee Official Data Specifications Manual.
3. Centers for Medicare and Medicaid Services. Professional paper claim form (CMS-1500).
4. CMS.gov. Medicare Claims Processing Manual.

By Joy Hicks
Joy B. Hicks, PhD, MBA, is an expert on the health insurance industry with over 15 years of experience in patient financial services.