UBO4 has 81 boxes in total. The UBO4 claim form is used by institutions to bill Medicare/Medicaid and other insurance companies. It is mandatory to enter all the Required fields-R. Missing the required field may lead to denial and insurance might delay the payment.
Below you can see two-column for inpatient and outpatient, Situational note is when you want it to be mandatory-you can add it. Please make sure you check twice when you fill in the patient’s name, date of birth. check the ID card and enter it carefully.
| Field location for UB04 | Description | Inpatient | Outpatient |
| 1 | Need to add Provider Name and Address | R | R |
| 2 | Pay-To Name and Address | Situational | Situational |
| 3a | Patient Control Number | R | R |
| 3b | Medical Record Number (MNR) | Situational | Situational |
| 4 | Type of Bill (TOB) | R | R |
| 5 | Federal Tax Number | R | R |
| 6 | Statement Covers Period | R | R |
| 7 | Future Use | N/A | N/A |
| 8a | Patient ID/Member ID | Situational | Situational |
| 8b | Patient Full Name | R | R |
| 9 | Patient Address | R | R |
| 10 | Patient Birthdate | R | R |
| 11 | Patient Sex | R | R |
| 12 | Admission Date | R | R, if applicable |
| 13 | Admission Hour | R | R, if applicable |
| 14 | Type of Admission/Visit | R | R |
| 15 | Source of Admission | R | R |
| 16 | Discharge Hour | R | N/A |
| 17 | Patient Discharge Status | R | R |
| 18-28 | Condition Codes | R, if applicable | R, if applicable |
| 29 | Accident State | Situational | Situational |
| 30 | Future Use | N/A | N/A |
| 31-34 | Occurrence Codes and Dates | R, if applicable | R, if applicable |
| 35-36 | Occurrence Span Codes and Dates | R, if applicable | R, if applicable |
| 37 | Future Use | N/A | N/A |
| 38 | Responsible Party Name and Address | R, if applicable | R, if applicable |
| 39-41 | Value Codes and Amounts | R, if applicable | R, if applicable |
| 42 | Revenue Code | R | R |
| 43 | Revenue Code Description | R | R |
| NDC Code | R, if applicable | R, if applicable | |
| 44 | HCPCS/Rates | R, if applicable | R, if applicable |
| 45 | Service Date | N/A | R |
| 46 | Units of Service | R | R |
| 47 | Total Charges (By Rev. Code) | R | R |
| 48 | Non-Covered Charges | R, if applicable | R, if applicable |
| 49 | Future Use | N/A | N/A |
| 50 | Payer Identification (Name) | R | R |
| 51 | Health Plan Identification Number | Situational | Situational |
| 52 | Release of Info Certification | R | R |
| 53 | Assignment of Benefit Certification | R | R |
| 54 | Prior Payments | R, if applicable | R, if applicable |
| 55 | Estimated Amount Due | R | R |
| 56 | NPI | R | R |
| 57 | Other Provider IDs | Optional | Optional |
| 58 | Insured’s Name | R | R |
| 59 | Patient’s Relation to the Insured | R | R |
| 60 | Insured’s Unique ID | R | R |
| 61 | Insured Group Name | Situational | Situational |
| 62 | Insured Group Number | Situational | Situational |
| 63 | Treatment Authorization Codes | R, if applicable | R, if applicable |
| 64 | Document Control Number | Situational | Situational |
| 65 | Employer Name | Situational | Situational |
| 66 | Diagnosis/Procedure Code Qualifier | R, if applicable | R, if applicable |
| 67 | Principal Diagnosis Code/Other Diagnosis Codes | R | R |
| 68 | Future Use | N/A | N/A |
| 69 | Admitting Diagnosis Code | R | R, if applicable |
| 70 | Patient’s Reason for Visit Code | Situational | Situational |
| 71 | PPS Code | Situational | Situational |
| 72 | External Cause of Injury Code | Situational | Situational |
| 73 | Future Use | N/A | N/A |
| 74 | Principal Procedure Code/Date | R, if applicable | R, if applicable |
| 75 | Future Use | N/A | N/A |
| 76 | Attending Name/ID-Qualifier 1G | R | R |
| 77 | Operating ID | Situational | Situational |
| 78-79 | Other ID | Situational | Situational |
| 80 | Remarks | Situational | Situational |
| 81 | Code-Code Field/Qualifiers | ||
| *0-A0 | N/A | N/A | |
| *A1-A4 | Situational | Situational | |
| *A5-AB | N/A | N/A | |
| AC – Attachment Control number | Situational | Situational | |
| AD-B0 | N/A | N/A | |
| *B1-B2 | Situational | Situational | |
| *B3 | R | R |
