UBO4 box Explanation and required fields description to submit the claim (2022)

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
*B1-B2 Situational Situational
*B3 R R

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