UB04- CMS 1450

UB-04 / CMS-1450

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The UB-04 form, also known as the CMS-1450 form, is a standardized claim form used by institutional healthcare providers in the United States to bill Medicare, Medicaid, and other insurance payers. It is primarily used by hospitals, nursing homes, ambulatory surgical centers, and other institutional providers to submit claims for reimbursement.

The form is maintained by the National Uniform Billing Committee (NUBC) and is essential for ensuring accurate and timely payment for services rendered. This article provides a detailed overview of the UB-04 form, including a brief description of each field and its purpose.

Overview of the UB-04 Form

The UB-04 form consists of 81 fields (also called form locators or FLs), each designed to capture specific information about the patient, provider, and services provided. The form is used to report inpatient, outpatient, and other institutional services, and it must be completed accurately to avoid claim denials or delays in payment.

Detailed Description of Key Fields

Section 1: Billing and Provider Information

  1. FL 1: Provider Name, Address, and Telephone Number
    • The name, address, and phone number of the facility submitting the claim.
  2. FL 2: Pay-to Name, Address, and City/State/ZIP
    • The name and address of the entity receiving payment (if different from the billing provider).
  3. FL 3: Patient Control Number
    • A unique identifier assigned by the provider to track the patient’s account.
  4. FL 4: Type of Bill (TOB)
    • A 4-digit code indicating the type of facility and type of care (e.g., inpatient, outpatient, hospice).
  5. FL 5: Federal Tax Number
    • The provider’s federal tax identification number.
  6. FL 6: Statement Covers Period
    • The start and end dates of the service period covered by the claim.

Section 2: Patient and Insurance Information

  1. FL 7: Untitled
    • Reserved for future use.
  2. FL 8: Patient Name
    • The full name of the patient receiving services.
  3. FL 9: Patient Address
    • The patient’s full address, including ZIP code.
  4. FL 10: Patient Birth Date
    • The patient’s date of birth.
  5. FL 11: Patient Sex
    • The patient’s gender (M/F).
  6. FL 12: Admission Date
    • The date the patient was admitted to the facility.
  7. FL 13: Admission Hour
    • The time of admission (in military time).
  8. FL 14: Type of Admission
    • A code indicating the type of admission (e.g., emergency, elective).
  9. FL 15: Source of Admission
    • A code indicating where the patient was admitted from (e.g., physician referral, transfer from another facility).
  10. FL 16: Discharge Hour
    • The time of discharge (in military time).
  11. FL 17: Patient Discharge Status
    • A code indicating the patient’s status at discharge (e.g., home, transferred to another facility).
  12. FL 18-28: Condition Codes
    • Codes indicating specific conditions related to the patient’s care (e.g., work-related injury, auto accident).
  13. FL 29: Accident State
    • The state where an accident occurred (if applicable).
  14. FL 30: Untitled
    • Reserved for future use.
  15. FL 31-34: Occurrence Codes and Dates
    • Codes and dates for specific events related to the claim (e.g., accident date, onset of symptoms).
  16. FL 35-36: Occurrence Span Codes and Dates
    • Codes and dates for periods of time related to the claim (e.g., non-covered days, leave of absence).
  17. FL 37: Untitled
    • Reserved for future use.
  18. FL 38: Responsible Party Name and Address
    • The name and address of the person responsible for payment (if different from the patient).

Section 3: Insurance Information

  1. FL 39-41: Value Codes and Amounts
    • Codes and amounts for specific financial data (e.g., total charges, covered charges).
  2. FL 42: Revenue Codes
    • Codes identifying the type of service provided (e.g., room and board, laboratory services).
  3. FL 43: Description of Services
    • A brief description of the services provided.
  4. FL 44: HCPCS/Rates/HIPPS Codes
    • Codes for specific procedures or services (e.g., CPT, HCPCS, or HIPPS codes).
  5. FL 45: Service Dates
    • The dates services were rendered.
  6. FL 46: Service Units
    • The number of units of service provided.
  7. FL 47: Total Charges
    • The total charges for each line item.
  8. FL 48: Non-Covered Charges
    • The amount of charges not covered by insurance.
  9. FL 49: Untitled
    • Reserved for future use.
  10. FL 50: Payer Name
    • The name of the primary insurance payer.
  11. FL 51: Health Plan ID
    • The identification number of the primary insurance plan.
  12. FL 52: Release of Information Indicator
    • Indicates whether the patient has authorized the release of medical information.
  13. FL 53: Assignment of Benefits Indicator
    • Indicates whether the patient has assigned benefits to the provider.
  14. FL 54: Prior Payments
    • The amount of prior payments made by the payer.
  15. FL 55: Estimated Amount Due
    • The estimated amount the patient owes.
  16. FL 56: National Provider Identifier (NPI)
    • The NPI of the billing provider.
  17. FL 57: Other Provider ID
    • Additional identification numbers for the provider.
  18. FL 58: Insured’s Name
    • The name of the person holding the insurance policy.
  19. FL 59: Patient’s Relationship to Insured
    • The patient’s relationship to the policyholder (e.g., self, spouse, child).
  20. FL 60: Insured’s Unique ID
    • The insured’s identification number.
  21. FL 61: Insurance Group Name
    • The name of the insurance group.
  22. FL 62: Insurance Group Number
    • The group number of the insurance plan.
  23. FL 63: Treatment Authorization Codes
    • Codes for treatment authorization (if required).
  24. FL 64: Document Control Number
    • A unique number assigned by the payer for tracking purposes.
  25. FL 65: Employer Name
    • The name of the patient’s employer.
  26. FL 66: Diagnosis and Procedure Codes
    • ICD-10 diagnosis codes and procedure codes related to the claim.
  27. FL 67: Principle Diagnosis Code
    • The primary diagnosis code for the claim.
  28. FL 68-75: Other Diagnosis Codes
    • Additional diagnosis codes (up to 24 codes can be reported).
  29. FL 76: Attending Provider NPI
    • The NPI of the attending physician.
  30. FL 77: Operating Physician NPI
    • The NPI of the operating physician (if applicable).
  31. FL 78: Other Provider NPI
    • The NPI of other providers involved in the patient’s care.
  32. FL 79: Remarks
    • Additional information or comments related to the claim.
  33. FL 80: Code-Code
    • Reserved for state-specific use.
  34. FL 81: Code-Code
    • Reserved for state-specific use.

Conclusion

The UB-04 form is a critical tool for institutional healthcare providers to ensure accurate and timely reimbursement for services rendered. Each field on the form serves a specific purpose, capturing essential information about the patient, provider, and services provided. Proper completion of the form is crucial to avoid claim denials or delays in payment. By understanding the purpose of each field, healthcare providers can streamline the billing process and maintain compliance with insurance requirements.

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