UB04 Claim Form or CMS-1450 Form

Claim form UB-04 is one of the very important claim forms required to be filled up by medical service providers for reimbursement of medical expenses. It is also known as CMS-1450 Form. Facilities like hospitals, rehabilitation centers, ambulatory surgery centers, clinics, etc need to bill their rendering services on the claim form UB04 in order to get paid. Individual medical providers like physicians are required to fill up claim form CMS1500.
Often medical providers get confused between the two forms claim form 1500 and claim form UB-04. It is very important to have a clear-cut understanding as regards the two forms. If a wrong form is filled up, the insurance carrier will straightway reject the claim.


There is a lot of information that needs to be filled up on claim form UB-04. Required fields on the UBO4 form include rev codes, value codes, and type of bill. What do you put in these fields? These forms can be very confusing. Where do you get the correct information to complete the forms? And which fields are required on the form? If the facility does not have the required form to fill out, where do you get one? The incomplete or incorrect information would lead to claim rejection.

Total 81 fields in a UB04 form and which divided into four parts:
1 Patient Information- Form Locator -01-41
2 Charge Information- Form Locator – 42-49
3 Insurance Information- Form Locator – 50-65
4 Diagnosis and CPT Information – Form Locator- 66-81

Detail Description of Each Form Locator(FL):
FL1 – Provider name and Address
FL2- Payment Address or Pay to Address
FL3- a- Pat Contact Number, b- MRN(Medical Record Number)
FL4- Type of Bill
FL5- Tax Id
FL6- Statement Covers Period
FL7- Unused
FL8- Patient Name
FL9- Patient Address
FL10- Patient date of birth
FL11- Gender
FL12- Admission date
FL13- Admission Hour
FL14- Admission Type
FL15- Source of Admission
FL16- Patient Discharge Hour
FL17- Patient Discharge Status (Where pat go like home, other hospital or SNF)
FL18-28 – Condition Codes
FL29- Patient accident date(When pat met with accident)
FL30- Unused
FL31-34 –Occurrence Code
FL35-36- Occurrence Span
FL37- Unused
FL38- Responsible Insurance Info(Which ins we bill claim)
FL39-41- Value Codes( Claim paid on basis of value codes)
FL42 – Revenue Codes (Start with zero and 4 digit codes)
FL43- Revenue code description
FL44- HCPCS and CPT codes
FL45- DOS (Date of Service)
FL46- Service Units
FL47- Total Charges
FL48- Non-Covered Charges
FL49- Unused
FL50- Payer Information
FL51- Health Plan Id
FL52- Release of Information Info (ROI Info)
FL53- Assignment of Benefit
FL54- Prior Payment Info
FL55- Estimated amount due
FL56- National Provider Identification Number (NPI)
FL57- Other Provider NPI
FL58- Insured Name
FL59- Relationship status
FL60- Insured Unique Id
FL61- Group Name
FL62- Insurance Group Number
FL63- Treatment Authorization Code
FL64- Document control number (DCN or ICN)
FL65- Employer Name
FL66- Dx Qualifier ( ICD9 or ICD10)
FL67- Primary diagnosis
FL68- Unused
FL69- Admission dx
FL70- Patient reason Dx
FL71- Prospective payment system code (APC or DRG)
FL72- External cause of Injury
FL73- Unused
FL74- Principle Procedure code(CPT)
FL75- Unused
FL76- Attending NPI
FL77- Operating NPI
FL78-79- Other NPI
FL80- Remarks Field
FL81- Taxonomy Qualifier

If you are preparing or working to make the career in USA Healthcare, go through all post of healthcare this will greatly help. we will back with more information.

You can see a UB04 form or purchase it from Amazon. Click here UB04 Form

Best wishes

All pictures and some description source-Google

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