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UB04 Claim Form

Below is an explanation of how each field on the printed UB04 Claim Form is populated for medical claims.

Some fields require Medical Insurance features to be enabled. If the Where Entered column for a field is N/A, information is not automatically populated from the database.

Note: Requirements for e-claims are different than requirements for paper claims. Printing a claim does not represent what is sent for an e-claim. Likewise, information sent for an e-claim does not necessarily print on a paper claim.

# Field Name on Form Where Entered
1 Billing Provider name and practice or clinic Pay To Address (if any). If there is no Pay To address, the Billing Address is used if Use On Claims is checked or the Physical Treating Address is used.
2 N/A
3a Pat Ctrl # Edit Patient Information, ChartNumber
3b Med Rec # N/A
4 Type of Bill Edit Claim - Medical Tab, Type of Bill
5 Fed Tax No Billing Provider SSN or TIN
6 Statement Covers Period From Through Edit Claim, Date of Service
7 Edit Insurance Plan, Other Ins Info tab, Insurance Filing Code. Shows XOVER when filinf code is set to Medicare Part B.
8 Patient Name
8a N/A
8b Edit Patient Information, First Name, Middle Initial, Last Name
9 a-c Patient Address Edit Patient Information, Address, City, State, Zip
9d N/A
10 Birthdate Edit Patient Information, Birthdate
11 Sex Edit Patient Information, Gender
12 Date Edit Claim, Date of Service
13 HR N/A
14 Type Edit Claim - Medical tab, Admission Type
15 SRC Edit Claim - Medical tab, Admission Source
16 DHR N/A
17 Stat Edit Claim - Medical tab, Patient Status
18 - 28 Condition Codes Edit Claim - Medical tab, Conditions Codes.
29 Acdt State Edit Claim - General Tab, Accident State
30 N/A
31 Code / Occurrence Date Edit Claim - General tab, Accident Related and Accident State
32 Code / Occurrence Date N/A
33 Code / Occurrence Date N/A
34 Code / Occurrence Date N/A
35 Code / Occurrence Date N/A
36 Code / Occurrence Date N/A
37 N/A
38 N/A
39 a-d Code / Value Codes Amount Edit Claim - Medical tab, Value Codes (39)
40 a-d Code / Value Codes Amount Edit Claim - Medical tab, Value Codes (40)
41 a-d Code / Value Codes Amount Edit Claim - Medical tab, Value Codes (41)
42 Rev. Cd. Procedure Info - Medical tab, Revenue Code. Up to 10.
43 Description Procedure Code, Description. Up to 10 codes.
44 HCPS / Rate / HIPPS Code Procedure - Medical tab, Mods. Mods are appended to the Procedure Code. Up to 10.
45 Serv. Date Procedure Info, Date
46 Serv. Units Procedure Info - Medical tab, Unit Quantity
47 Total Charges Edit Claim Procedure, Fee Billed to Ins
48 Non-Covered Charges N/A
49 N/A
42 Totals Total number of procedures on the claim.
Page _ of _ Page 1 of 1 by default.
Creation Date Edit Claim, Date of Service
47 Totals Total of amounts in the #47 column for all rows. Total claim billed amount.
48 Totals N/A
50 a-c Payer Name Edit Insurance Plan, Carrier. Information is only shown on one row. The row used depends on the Insurance Plan Order.
51 a-c Health Plan ID N/A
52 a-c Rel. Info Edit Insurance Plan, Release of Information. When checked, shows as X on the claim form. Information is only shown on one row. The row used depends on the Insurance Plan Order.
53 a-c Asg. Ben. Edit Insurance Plan, Assignment of Benefits. When checked, shows as X on the claim form.
54 a-c Prior Payments Ins Pay amount from other other claims. Information is only shown on one row. The row used depends on the Insurance Plan Order.
55 a-c Est. Amount Due Calculated by Total Charges - Prior Payments
56 a-c NPI Billing Dentist NPI
57 a-c Other Prv ID Edit Provider, Supplemental IDs, Supplemental Provider Identifiers. Only the ID Number matching the carrier's Payor ID is used. Information is only shown on one row. The row used depends on the Insurance Plan Order.
58 a-c Insured's Name Edit Insurance Plan, Subscriber Name. Information is only shown on one row. The row used depends on the Insurance Plan Order.
59 a-c P. Rel Edit Insurance Plan, Relationship to Subscriber
60 a-c Insured's Unique ID Edit Insurance Plan, Subscriber ID. Information is only shown on one row. The row used depends on the Insurance Plan Order.
61 a-c Group Name Edit Insurance Plan, Group Name. Up to three medical insurance plans.
62 a-c Insurance Group No. Edit Insurance Plan, Group Num. Information is only shown on one row. The row used depends on the Insurance Plan Order.
63 a-c Treatment Authorization Codes Edit Claim, Predeterm Benefits
64 a-c Document Control Number N/A
65 a-c Employer Name Edit Insurance Plan, Employer. Information is only shown on one row. The row used depends on the Insurance Plan Order.
66 Dx Edit Procedure, Diagnosis Code. Up to 4.
68 N/A
69 Admit Dx N/A
70 Patient Reason Dx N/A
71 PPS Code N/A
72 ECI N/A
73 N/A
74 Principal Procedure Code / Date N/A
74a Other Procedure Code / Date N/A
74b Other Procedure Code / Date N/A
74c Other Procedure Code / Date N/A
74d Other Procedure Code / Date N/A
74e Other Procedure Code / Date N/A
75 N/A
76 Attending NPI / Qual / Last / First N/A
77 Operating NPI / Qual / Last / First Treating Provider, National Provider ID, Last Name, First Name
78 Other NPI / Qual / Last / First N/A
79 Other NPI / Qual / Last / First N/A
80 Remarks Edit Claim - General, Claim Note
81 a-d CC N/A