UB-04 claims submission guide
05/2017
The UB-04 claim form, also known as the CMS-1450 form, is approved by the Centers for Medicare & Medicaid
Services (CMS) and the National Uniform Billing Committee for facility and ancillary paper billing. Sample UB-04 forms
for inpatient and outpatient claims can be found on pages 4 and 5.
If you have any questions regarding the UB-04 claim form, please call your Network Coordinator or Customer Service at
1-800-ASK-BLUE.
UB-04 data field requirements
Field location
UB-04
1
2
3a
3b
4
5
6
7
8a
8b
9a-e
10
11
12
13
14
15
16
17
18-28
29
30
31-34
35-36
37
38
39-41
42
43
44
45
46
47
Description
Inpatient
Outpatient
Provider Name and Address
Pay-To Name and Address
Patient Control Number
Medical Record Number
Type of Bill
Federal Tax ID Number
Statement Covers Period
Future Use
Patient ID
Patient Name
Patient Address
Patient Birthdate
Patient Sex
Admission Date
Admission Hour
Type of Admission/Visit
Source of Admission
Discharge Hour
Patient Discharge Status
Condition Codes
Accident State
Future Use
Occurrence Codes and Dates
Occurrence Span Codes and Dates
Future Use
Responsible Party Name and Address
Value Codes and Amounts
Revenue Code
Revenue Code Description
NDC Code
HCPCS/Rates
Service Date
Units of Service
Total Charges (by Revenue Code)
Required
Situational
Required
Situational
Required
Required
Required
N/A
Situational
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required, if applicable
Situational
N/A
Required, if applicable
Required, if applicable
N/A
Required, if applicable
Required, if applicable
Required
Required
Required, if applicable
Required, if applicable
N/A
Required
Required
Required
Situational
Required
Situational
Required
Required
Required
N/A
Situational
Required
Required
Required
Required
Required, if applicable
Required, if applicable
Required
Required
N/A
Required
Required, if applicable
Situational
N/A
Required, if applicable
Required, if applicable
N/A
Required, if applicable
Required, if applicable
Required
Required
Required, if applicable
Required, if applicable
Required
Required
Required
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and
QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
1
05/2017
Field location
UB-04
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78-79
80
81
Description
Inpatient
Outpatient
Non-Covered Charges
Future Use
Payer Name
Health Plan ID
Release of Information Certification
Assignment of Benefit Certification
Prior Payments
Estimated Amount Due
NPI
Other Provider IDs
Insured’s Name
Patient’s Relation to the Insured
Insured’s Unique ID
Insured’s Group Name
Insured’s Group Number
Treatment Authorization Codes
Document Control Number
Employer Name
Diagnosis/Procedure Code Qualifier
Principal Diagnosis Code/Other Diagnosis Codes
Future Use
Admitting Diagnosis Code
Patient’s Reason for Visit Code
PPS Code
External Cause of Injury Code
Future Use
Principal Procedure Code/Date
Future Use
Attending Provider Name/NPI
Operating Physician Name/NPI
Other Provider Name/NPI
Remarks
Code-Code Field/Qualifiers
0-A0
A1-A4
A5-AB
AC - Attachment Control number
AD-B0
B1-B2
B3 Taxonony Code Qulifier
Required, if applicable
N/A
Required
Situational
Required
Required
Required, if applicable
Required
Required
Optional
Required
Required
Required
Situational
Situational
Required, if applicable
Situational
Situational
Required
Required
N/A
Required
N/A
Situational
Situational
N/A
Required, if applicable
N/A
Required
Situational
Situational
Situational
Required, if applicable
N/A
Required
Situational
Required
Required
Required, if applicable
Required
Required
Optional
Required
Required
Required
Situational
Situational
Required, if applicable
Situational
Situational
Required
Required
N/A
Required, if applicable
Situational
Situational
Situational
N/A
N/A
N/A
Required
Situational
Situational
Situational
N/A
Situational
N/A
Situational
N/A
Situational
Required
N/A
Situational
N/A
Situational
N/A
Situational
Required
2
05/2017
Readability requirements
To ensure that all claims are processed against the same requirements, paper claims are converted to an electronic
format. However, system limitations can cause data elements to be misinterpreted during the conversion process.
Follow these guidelines to ensure your claims are successfully converted:
Do
• Use red drop on UB-04 paper forms only.
• Replacement/corrected claims require a Type of Bill with
a Frequency Code “7” (field 4) and claim number in the
Document Control Number (field 64).
• Enter all required data.
• All patient details are required (ID number with prefix, last
name, first name, and date of birth).
• Separate the subscriber/patient last name and first name
with a comma.
• Ensure the use of proper coding (ICD-10 HIPAA codes,
dates of service, and correcting a prior claim).
• Use standard fonts and sizes.
Don’t
• Do not include handwriting anywhere on the claim form.
• Do not use stamped data in any field (NPI, provider
names, signatures, corrections, etc.).
• Do not print claim data out of the designated field; it may
not be captured.
• Do not print from an older DOT matrix printer; it may not
be captured.
3
05/2017
Inpatient
__
__
Any Hospital
123 Any Street
__
1
8 PATIENT
NAME
a
11 SEX
03 20 1971
a
12
ADMISSION
13 HR 14 TYPE
DATE
3
08
11 03 06
M
31
OCCURRENCE
COD E
DATE
b
Patient ID if different from Sub
32
OCCURRENCE
CODE
DATE
15 SRC
PA 19103
9 PATIENT
ADDRESS
16 DHR 17 ST AT
3
12
18
221234567
ST ATEMENT
F R OM
RESERVED
11 04 06
1234 Main Street
CONDITION CODES
24
22
23
21
20
34
OCCURRENCE
COD E
DATE
7
CO VERS PERIOD
TH R OUGH
11 03 06
PA
c
19
35
CODE
OCCURRENCE
F R OM
25
26
27
36
COD E
S PAN
THR OUGH
Country
e code if
other than USA
19111
d
29 AC DT 30
ST ATE
28
PA
OCCURRENCE
F R OM
RESERVED
37
S PAN
TH R OUGH
FUTURE
USE
Occurrence and Occurrence Span Codes may be used to define a significant event that may affect payer processing
38
39
CODE
John Doe
1234 Main Street
Philadelphia, PA 19111
40
CODE
VALUE CODES
AMOUNT
a A1
b Value
TYPE
OF BILL
0111
6
5 FE D. TAX NO.
Co n d i t i o n Co d e s R e q u i re d I d e n t i f yi n g Ev e n t s
01
33
OCCURRENCE
DATE
CODE
a
4
1234
98765
Philadelphia
b
10 BI R TH DATE
3a PAT.
CNTL #
b. MED .
REC . #
Philadelphia
PA 19103
Doe, John
b
Any Hospital
456 Any Street
2
Philadelphia
__
41
CODE
VALUE CODES
AMOUNT
a
b
VALUE CODES
AMOUNT
952 00
Codes and amounts required when necessary to process claim
c
d
42 RE V. C D.
1
2
3
44 HCPCS / R ATE / HIPPS CODE
43 DESCRIPTION
0129
0250
0360
45 SE R V. DATE
46 SE R V. UNITS
200.00
Semi-Private
Pharmacy
OR Services
47 TOTAL CHARGES
2
1
48 NON-COVERED CHARGES
400 00
0 00
0 00
0 00
50 00
100 00
49
1
FUTURE
USE
2
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
Red = Required
Black = Situational/Required, if applicable/Optional
11
12
11
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
PAGE 1
23
50 PAYER
1
OF
CREATION DATE
NAME
51 HEALTH PLAN ID
A
Independence Blue Cross
B
Secondary Payer
58 INSURED ’S
NAME
59 P. REL
Doe, John
A
53 ASG.
BEN.
Y
Y
Report HIPAA National
Health Plan Identifier
when mandatory
Tertiary Payer
C
52 REL .
INFO
18
60 INSURED’S
550 00
TOTALS
55 ES T. AMOUNT DUE
54 PRIOR PAYMENTS
Required when
indicated payer has
paid amount to
Provider
56 NPI
Amount
estimated
to be due
57
OTHER
PR V ID
62 INSURANCE
61 G R OUP NAME
UNI QUE ID
C
63 TREATMENT
C
66
DX
C
AUTHORIZATION
67
I
64 DOCUMENT
CODES
3749
OTHER
CODE
65 EMPL OYER
CONTR OL NUMBER
491234
Watch Repair, Inc.
Use the appropriate ICD indicator and code set
B
K
A
J
C
L
E
N
A
D
M
OTHER
CODE
PROCEDURE
DATE
b.
OTHER
CODE
PROCEDURE
DATE
e.
71 PPS
DRG
COD E
OTHER P R OCEDURE
CODE
DATE
11 03 06
PROCEDURE
DATE
d.
C
F
O
72
EC I
G
P
81CC
a
80 REMARKS
May be used to report additional
information.
b
c
OTHER P R OCEDURE
CODE
DATE
77 OPERATING
B3 282N00000X
78 OTHER
Secondary
NPI
Tertiary
79 OTHER
LAST
™
National Uni form
Reserved
73
LIC9213257
QUAL
FI RST
NPI
LAST
NUBC
68
Reserved
May be used to report external cause of injury
QUAL
76 ATTENDING
NPI 2 2 2 2 2 2 2 2 2 2
Reserved LAST S m i t h
FI RST
D av id
d
APPROVED OMB NO .
H
Q
75
LAST
UB-04 CMS-1450
NAME
B
69 ADMIT
70 PATIENT
4280
DX
REASON DX
PRINCI PAL P R OCEDURE
a.
74
CODE
DATE
c.
C
B
02468
Secondary
Tertiary
A
B
A
B
A
Secondary
Tertiary
B
23
G R OUP NO.
1234
Watch Repair, Inc.
ABC1234567800
2 2 2 2 2 2 2 222
1 2 3 4 5 6 7 890
Secondary
Tertiary
0 00
QUAL
FI RST
NPI
QUAL
FI RST
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
4
05/2017
Outpatient
__
__
Any Hospital
123 Any Street
__
1
8 PATIENT
NAME
a
11 SEX
03 20 1971
12
ADMISSION
13 HR 14 TYPE
DATE
3
08
11 03 06
M
31
OCCURRENCE
COD E
DATE
a
9 PATIENT
32
OCCURRENCE
CODE
DATE
15 SRC
ADDRESS
16 DHR 17 ST AT
3
18
221234567
ST ATEMENT
F R OM
20
34
OCCURRENCE
COD E
DATE
RESERVED
11 04 06
1234 Main Street
PA
c
19
7
CO VERS PERIOD
TH R OUGH
11 03 06
CONDITION CODES
24
22
23
21
25
26
27
35
CODE
OCCURRENCE
F R OM
36
COD E
S PAN
THR OUGH
Country
e code if
other than USA
19111
d
29 AC DT 30
ST ATE
28
Co n d i t i o n Co d e s R e q u i re d I d e n t i f yi n g Ev e n t s
01
33
OCCURRENCE
DATE
CODE
a
PA
OCCURRENCE
F R OM
RESERVED
37
S PAN
TH R OUGH
FUTURE
USE
Occurrence and Occurrence Span Codes may be used to define a significant event that may affect payer processing
38
39
CODE
John Doe
1234 Main Street
Philadelphia, PA 19111
40
CODE
VALUE CODES
AMOUNT
a A1
b Value
TYPE
OF BILL
0131
6
5 FE D. TAX NO.
Philadelphia
b
10 BI R TH DATE
b
Patient ID if different from Sub
PA 19103
4
1234
98765
3a PAT.
CNTL #
b. MED .
REC . #
Philadelphia
PA 19103
Doe, John
b
Any Hospital
456 Any Street
2
Philadelphia
__
41
COD E
VALUE CODES
AMOUNT
a
b
VALUE CODES
AMOUNT
952 00
Codes and amounts required when necessary to process claim
c
d
42 REV. C D.
1
2
3
44 HCPCS / R ATE / HIPPS CODE
43 DESCRIPTION
0310
0402
0360
45 SER V DATE
88173
76942
Laboratory N400093723106
Ultrasoud
OR Services
46 SERV. UNITS
11 03 06
11 04 06
11 04 06
3749
47 TOTAL CHARGES
1
1
1
48 NON-COVERED CHARGES
49
1
0 00 Future
Use
2
0 00
3
0 00
100 00
100 00
100 00
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
Red = Required
Black = Situational/Required, if applicable/Optional
12
13
14
12
13
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
PAGE 1
23
50 PAYER
1
OF
CREATION DATE
NAME
51 HEALTH PLAN ID
A
Independence Blue Cross
B
Secondary Payer
58 INSURED’S
NAME
59 P. REL
Doe, John
A
53 ASG.
BEN.
Y
Y
Report HIPAA National
Health Plan Identifier
when mandatory
Tertiary Payer
C
52 REL .
INFO
18
60 INSURED’S
300 00
TOTALS
55 EST. AMOUNT DUE
54 PRIOR PAYMENTS
Required when
indicated payer has
paid amount to
Provider
56 NPI
Amount
estimated
to be due
57
OTHER
PR V ID
62 INSURANCE
61 G ROUP NAME
UNIQUE ID
C
63 TREATMENT
C
66
DX
C
AUTHORIZATION
67
I
64 DOCUMENT
CODES
OTHER
CODE
65 EMPLOYER
CONTR OL NUMBER
491234
Watch Repair, Inc.
Use the appropriate ICD indicator and code set
A
J
PROCEDURE
DATE
d.
a
B
K
D
M
C
L
E
N
A
71 PPS
DRG
COD E
OTHER P R OCEDURE
CODE
DATE
May be used to report reason for visit
OTHER
CODE
PROCEDURE
DATE
b.
OTHER
CODE
PROCEDURE
DATE
e.
72
EC I
C
F
O
G
P
81CC
a
80 REMARKS
May be used to report additional
information.
b
c
OTHER P R OCEDURE
CODE
DATE
77 OPER ATING
B3 282N00000X
78 OTHER
Secondary
NPI
Tertiary
79 OTHER
LAST
™
National Uni form
Reserved
73
LIC9213257
QUAL
FI RST
NPI
LAST
NUBC
68
Reserved
May be used to report external cause of injury
QUAL
76 ATTENDING
NPI 2 2 2 2 2 2 2 2 2 2
Reserved LAST S m i t h
FI RST
D av i d
d
APPR OVED OMB NO .
H
Q
75
LAST
UB-04 CMS-1450
NAME
B
69 ADMIT
70 PATIENT
4280
DX
REASON DX
PRINCIPAL P R OCEDURE
a.
74
CODE
DATE
c.
C
B
02468
Secondary
Tertiary
A
B
A
B
A
Secondary
Tertiary
B
23
G R OUP NO.
1234
Watch Repair, Inc.
ABC1234567800
2 2 2 2 2 2 2 222
1 2 3 4 5 6 7 8 90
Secondary
Tertiary
0 00
QUAL
FI RST
NPI
QUAL
FI RST
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
5