UB-04 Claim Form Instructions

Required (R) fields must be completed on all claims. Conditional (C) fields must
be completed if the information applies to the situation or the service provided.
NOTE: Claims with missing or invalid Required (R) field information will be
rejected or denied.

Required or
Field # Field Description Instructions and Comments Conditional*
Line 1: Enter the complete provider name.
Line 2: Enter the complete mailing address.
1 (UNLABELED FIELD) Line 3: Enter the City, State, and zip+4 code (include R
hyphen)
Line 4: Enter the area code and phone number.
2 (UNLABELED FIELD) Enter the Pay-To Name and Address. Not Required
Enter the facility patient account/control number
3a PATIENT CONTROL NO. Not Required

MEDICAL RECORD Enter the facility patient medical or health record number.
3b R
NUMBER
Enter the appropriate 3-digit type of bill (TOB) code as
specified by the NUBC UB-04 Uniform Billing Manual
minus the leading 0 (zero). A leading 0 is not
4 TYPE OF BILL needed. Digits should be reflected as follows: R
1st digit - Indicating the type of facility.
2nd digit - Indicating the type of care
3rd digit - Indicating the billing sequence.
Enter the 9-digit number assigned by the federal
5 FED. TAX NO. government for tax reporting purposes. R

Enter begin and end or admission and discharge dates for

the services billed. Inpatient and outpatient observation
STATEMENT COVERS stays must be billed using the admission date and
6 PERIOD discharge date. Outpatient therapy, chemotherapy, R
FROM/THROUGH laboratory, pathology, radiology and dialysis may be billed
using a date span. All other outpatient services must be
billed using the actual date of service. (MMDDYY)
7 (UNLABELED FIELD) Not Used Not Required
8a Enter the patients 10-digit Medicaid identification
number on the members CENPATICO BEHAVIORAL
Not Required
HEALTH I.D. card.

8b Enter the patients last name, first name, and middle

initial as it appears on the CENPATICO BEHAVIORAL
HEALTH ID card. Use a comma or space to separate the
8 last and first names.
PATIENT NAME
a-b
Titles (Mr., Mrs., etc.) should not be reported in this
field. R
Prefix: No space should be left after the prefix of a
name e.g. McKendrick. H
Hyphenated names: Both names should be
capitalized and separated by a hyphen (no space).
Suffix: A space should separate a last name and
suffix.
Enter the patients complete mailing address of the
patient.
Line a: Street address
9 R
PATIENT ADDRESS Line b: City
a-e (except line 9e)
Line c: State
Line d: ZIP code
Line e: Country Code (NOT REQUIRED)
10 BIRTHDATE Enter the patients date of birth (MMDDYYYY) R
11 SEX Enter the patient's sex. Only M or F is accepted. R
Enter the date of admission for inpatient claims and date
12 ADMISSION DATE of service for outpatient claims. R
Enter the time using 2-digit military time (00-23) for the
time of inpatient admission or time of treatment for
outpatient services.

00-12:00 midnight to 12:59 12- 12:00 noon to 12:59

01- 01:00 to 01:59 13- 01:00 to 01:59
02- 02:00 to 02:59 14- 02:00 to 02:59
03- 03:00 to 03:39 15- 03:00 to 03:59
13 ADMISSION HOUR R
04- 04:00 to 04:59 16- 04:00 to 04:59
05- 05:00 to 05:59 17- 05:00 to 05:59
06- 06:00 to 06:59 18- 06:00 to 06:59
07- 07:00 to 07:59 19- 07:00 to 07:59
08- 08:00 to 08:59 20- 08:00 to 08:59
09- 09:00 to 09:59 21- 09:00 to 09:59
10- 10:00 to 10:59 22- 10:00 to 10:59
11- 11:00 to 11:59 23- 11:00 to 11:59
Required for inpatient admissions (TOB 11X, 118X, 21X,
41X). Enter the 1-digit code indicating the priority of the
admission using one of the following codes:
14 ADMISSION TYPE 1 Emergency C
2 Urgent
3 Elective
4 Newborn
Enter the 1-digit code indicating the source of the
15 ADMISSION SOURCE R
admission or outpatient service using one of the following
 codes:
1 Physician Referral
2 Clinic Referral
4 Transfer from a hospital
6 Transfer from another health care facility
7 Emergency Room
8 Court/Law enforcement
9 Information not available
Enter the time using 2-digit military time (00-23) for the
time of inpatient or outpatient discharge.

00-12:00 midnight to 12:59 12- 12:00 noon to 12:59

01- 01:00 to 01:59 13- 01:00 to 01:59
02- 02:00 to 02:59 14- 02:00 to 02:59
03- 03:00 to 03:39 15- 03:00 to 03:59
16 DISCHARGE HOUR 04- 04:00 to 04:59 16- 04:00 to 04:59 Not Required
05- 05:00 to 05:59 17- 05:00 to 05:59
06- 06:00 to 06:59 18- 06:00 to 06:59
07- 07:00 to 07:59 19- 07:00 to 07:59
08- 08:00 to 08:59 20- 08:00 to 08:59
09- 09:00 to 09:59 21- 09:00 to 09:59
10- 10:00 to 10:59 22- 10:00 to 10:59
11- 11:00 to 11:59 23- 11:00 to 11:59
REQUIRED for inpatient claims. Enter the 2-digit
disposition of the patient as of the through date for the
billing period listed in field 6 using one of the following
codes:

STATU Description
S
01 Discharged to home or self care
02 Transferred to another short-term general
hospital
03 Transferred to a SNF
04 Transferred to an ICF
05 Transferred to another type of institution
17 PATIENT STATUS 06 Discharged home to care of home health C
07 Left against medical advice
08 Discharged home under the care of a Home
IV provider
20 Expired
30 Still patient or expected to return for
outpatient services
31 Still patient SNF administrative days
32 Still patient ICF administrative days
62 Discharged/Transferred to an IRF, distinct
rehabilitation unit of a hospital
65 Discharged/Transferred to a psychiatric
hospital or distinct psychiatric unit of a
hospital
 REQUIRED when applicable. Condition codes are used to
identify conditions relating to the bill that may affect payer
processing.

Each field (18-24) allows entry of a 2-character code.

18-28 CONDITION CODES Codes should be entered in alphanumeric sequence C
(numbered codes precede alphanumeric codes).

For a list of codes and additional instructions refer to the

NUBC UB-04 Uniform Billing Manual.

29 ACCIDENT STATE Not Required

30 (UNLABELED FIELD) Not Used Not Required

Occurrence Code: REQUIRED when applicable.

Occurrence codes are used to identify events relating to
the bill that may affect payer processing.

Each field (31-34a) allows entry of a 2-character code.

Codes should be entered in alphanumeric sequence
OCCURRENCE CODE (numbered codes precede alphanumeric codes).
31-34
and C
a-b
OCCURENCE DATE For a list of codes and additional instructions refer to the
NUBC UB-04 Uniform Billing Manual.

Occurrence Date: REQUIRED when applicable or when

a corresponding Occurrence Code is present on the same
line (31a-34a). Enter the date for the associated
occurrence code in MMDDYYYY format.

Occurrence Span Code: REQUIRED when applicable.

Occurrence codes are used to identify events relating to
the bill that may affect payer processing.
OCCURRENCE SPAN
35-36 CODE Each field (31-34a) allows entry of a 2-character code.
C
a-b and Codes should be entered in alphanumeric sequence
OCCURRENCE DATE (numbered codes precede alphanumeric codes).

For a list of codes and additional instructions refer to the

NUBC UB-04 Uniform Billing Manual.
 Occurrence Span Date: REQUIRED when applicable or
when a corresponding Occurrence Span code is present
on the same line (35a-36a). Enter the date for the
associated occurrence code in MMDDYYYY format.
REQUIRED for re-submissions or adjustments. Enter the
12-character DCN (Document Control Number) of the
original claim. A resubmitted claim MUST be marked
37 (UNLABELED FIELD) using large bold print within the body of the claim form C
with RESUBMISSION to avoid denials for duplicate
submission. NOTE: Re-submissions may NOT currently
be submitted via EDI.

RESPONSIBLE PARTY
38 Not Required
NAME AND ADDRESS

Code: REQUIRED when applicable. Value codes are

used to identify events relating to the bill that may affect
payer processing.

Each field (39-41) allows entry of a 2-character code.

Codes should be entered in alphanumeric sequence
(numbered codes precede alphanumeric codes).

Up to 12 codes can be entered. All a fields must be

completed before using b fields, all b fields before
using c fields, and all c fields before using d fields.
39-41 VALUE CODES
C
a-d CODES and AMOUNTS
For a list of codes and additional instructions refer to the
NUBC UB-04 Uniform Billing Manual.

Amount: REQUIRED when applicable or when a Value

Code is entered. Enter the dollar amount for the
associated value code. Dollar amounts to the left of the
vertical line should be right justified. Up to 8 characters
are allowed (i.e. 199,999.99). Do not enter a dollar sign
($) or a decimal. A decimal is implied. If the dollar amount
is a whole number (i.e. 10.00), enter 00 in the area to the
right of the vertical line.

General The following UB-04 fields 42-47:

Information Have a total of 22 service lines for claim detail information.
Service Line Detail
Fields Fields 42, 43, 45, 47, 48 include separate instructions for the
42-47 completion of lines 1-22 and line 23.
 Enter the appropriate 4 digit revenue codes itemizing
accommodations, services, and items furnished to the
patient. Refer to the NUBC UB-04 Uniform Billing Manual
42 for a complete listing of revenue codes and instructions.
REV CD R
Line 1-22
Enter accommodation revenue codes first followed by
ancillary revenue codes. Enter codes in ascending
numerical value.
42
Rev CD Enter 0001 for total charges. R
Line 23
43 Enter a brief description that corresponds to the revenue
DESCRIPTION R
Line 1-22 code entered in the service line of field 42.
Enter the number of pages. Indicate the page sequence
43 in the PAGE field and the total number of pages in the
PAGE ___ OF ___ R
Line 23 OF field. If only one claim form is submitted enter a 1
in both fields (i.e. PAGE 1 OF 1).
REQUIRED for outpatient claims when an appropriate
CPT/HCPCS code exists for the service line revenue code
billed. The field allows up to 9 characters. Only one
CPT/HCPC and up to two modifiers are accepted. When
entering a CPT/HCPCS with a modifier(s) do not use a
spaces, commas, dashes or the like between the
CPT/HCPC and modifier(s)

Refer to the NUBC UB-04 Uniform Billing Manual for a

44 HCPCS/RATES complete listing of revenue codes and instructions. C

The following revenue codes/revenue code ranges must

always have an accompanying CPT/HCPC.

300-302 329-330 360-361 610-612

304-307 333 363-366 615-616
309-312 340-342 368-369 618-619
314 349-352 400-404 634-636
319-324 359 490-499 923
45 REQUIRED on all outpatient claims. Enter the date of
SERVICE DATE C
Line 1-22 service for each service line billed. (MMDDYY)
45 Enter the date the bill was created or prepared for
CREATION DATE R
Line 23 submission on all pages submitted. (MMDDYY)
Enter the number of units, days, or visits for the service. A
46 SERVICE UNITS R
value of at least 1 must be entered.
47
TOTAL CHARGES Enter the total charge for each service line. R
Line 1-22
47
TOTALS Enter the total charges for all service lines. R
Line 23
Enter the non-covered charges included in field 47 for the
48 NON-COVERED
revenue code listed in field 42 of the service line. Do not C
Line 1-22 CHARGES
list negative amounts.
48
TOTALS Enter the total non-covered charges for all service lines. C
Line 23
49 (UNLABELED FIELD) Not Used Not Required
 Enter the name for each Payer reimbursement is being
50
PAYER sought in the order of the Payer liability. Line A refers to R
A-C
the primary payer; B, secondary; and C, tertiary.
HEALTH PLAN
51
IDENTIFICATION Not Required
A-C
NUMBER
REQUIRED for each line (A, B, C) completed in field 50.
Release of Information Certification Indicator. Enter Y
(yes) or N (no).
52
REL. INFO R
A-C
Providers are expected to have necessary release
information on file. It is expected that all released invoices
contain "Y.
Enter Y" (yes) or "N" (no) to indicate a signed form is on
53 ASG. BEN. file authorizing payment by the payer directly to the R
provider for services.
Enter the amount received from the primary payer on the
54 PRIOR PAYMENTS appropriate line when Medicaid/ CENPATICO C
BEHAVIORAL HEALTH is listed as secondary or tertiary.
55 EST. AMOUNT DUE Not Required

NATIONAL PROVIDER
56 IDENTIFIER or Required: Enter providers 10-character NPI ID. R
PROVIDER ID

Enter the qualifier 1D followed by your 6-digit Medicaid

57 OTHER PROVIDER ID Not Required
Provider ID number.
For each line (A, B, C) completed in field 50, enter the
name of the person who carries the insurance for the
58 INSURED'S NAME R
patient. In most cases this will be the patients name.
Enter the name as last name, first name, middle initial.
PATIENT
59 Not Required
RELATIONSHIP
REQUIRED: Enter the patient's Insurance/Medicaid ID
exactly as it appears on the patient's ID card. Enter the
60 INSUREDS UNIQUE ID R
Insurance /Medicaid ID in the order of liability listed in field
50.
61 GROUP NAME Not Required
 INSURANCE GROUP
62 Not Required
NO.
TREATMENT
63 AUTHORIZATION Not Required
CODES
Enter the 12-character Document Control Number (DCN)
of the paid CENPATICO BEHAVIORAL HEALTH claim
when submitting a replacement or void on the
corresponding A, B, C line reflecting CENPATICO
DOCUMENT CONTROL
64 BEHAVIORAL HEALTH from field 50. C
NUMBER
Applies to claim submitted with a Type of Bill (field 4)
Frequency of 7 (Replacement of Prior Claim) or Type of
Bill Frequency of 8 (Void/Cancel of Prior Claim).
65 EMPLOYER NAME Not Required

66 DX Not Required

Enter the principal/primary diagnosis or condition (the

condition established after study that is chiefly responsible
for causing the visit) using the appropriate release/update
of ICD-9-CM Volume 1& 3 for the date of service.
PRINCIPAL DIAGNOSIS
67 Diagnosis codes submitted must be a valid ICD-9 codes R
CODE
for the date of service and carried out to its highest digit
4th or5. "E" and most V codes are NOT acceptable as a
primary diagnosis.
NOTE: Claims missing or with invalid diagnosis codes will
be denied for payment.
Enter additional diagnosis or conditions that coexist at the
time of admission or that develop subsequent to the
admission and have an effect on the treatment or care
67 OTHER DIAGNOSIS
received using the appropriate release/update of ICD-9- C
A-Q CODE
CM Volume 1& 3 for the date of service.

Diagnosis codes submitted must be a valid ICD-9 codes

 for the date of service and carried out to its highest digit
4th or5. "E" and most V codes are NOT acceptable as a
primary diagnosis.

NOTE: Claims with incomplete or invalid diagnosis codes

will be denied for payment.
68 (UNLABELED) Not Used Not Required
Enter the diagnosis or condition provided at the time of
admission as stated by the physician using the
appropriate release/update of ICD-9-CM Volume 1& 3 for
the date of service.

ADMITTING DIAGNOSIS Diagnosis codes submitted must be a valid ICD-9 codes

69 R
CODE for the date of service and carried out to its highest digit
4th or5. "E" codes and most V are NOT acceptable as a
primary diagnosis.

NOTE: Claims missing or with invalid diagnosis codes will

be denied for payment.
Enter the ICD-9-CM code that reflects the patients reason
for visit at the time of outpatient registration. 70a requires
entry, 70b-70c are conditional.

Diagnosis codes submitted must be a valid ICD-9 codes

70 PATIENT REASON
for the date of service and carried out to its highest digit R
a,b,c CODE
4th or5. "E" codes and most V are NOT acceptable as a
primary diagnosis.

NOTE: Claims missing or with invalid diagnosis codes will

be denied for payment.
71 PPS / DRG CODE Not Required
72 EXTERNAL CAUSE
Not Required
a,b,c CODE
73 (UNLABELED) Not Required
REQUIRED on inpatient claims when a procedure is
performed during the date span of the bill.

CODE: Enter the ICD-9 procedure code that identifies the

PRINCIPAL principal/primary procedure performed. Do not enter the
74 PROCEDURE decimal between the 2nd or 3rd digits of code. It is implied. C
CODE / DATE
DATE: Enter the date the principal procedure was
performed (MMDDYY).

REQUIRED for EDI Submissions.

REQUIRED on inpatient claims when a procedure is
performed during the date span of the bill.

CODE: Enter the ICD-9 procedure code(s) that identify

74 OTHER PROCEDURE
significant a procedure(s) performed other than the C
a-e CODE DATE
principal/primary procedure. Up to 5 ICD-9 procedure
codes may be entered. Do not enter the decimal between
the 2nd or 3rd digits of code. It is implied.
 DATE: Enter the date the principal procedure was
performed (MMDDYY).
75 (UNLABELED) Not Required
Enter the NPI and Name of the physician in charge of the
patient care:

NPI: Enter the attending physician 10-character NPI ID.

Taxonomy Code: Enter valid taxonomy code

QUAL: Enter one of the following qualifier and ID number

76 ATTENDING PHYSICIAN 0B State License # R
1G Provider UPIN
G2 Provider Commercial #
ZZ Taxonomy Code

LAST: Enter the attending physicians last name

FIRST: Enter the attending physicians first name.

REQUIRED when a surgical procedure is performed:

NPI: Enter the operating physician 10-character NPI ID.

Taxonomy Code: Enter valid taxonomy code

QUAL: Enter one of the following qualifier and ID number

OPERATING 0B State License #
77 1G Provider UPIN C
PHYSICIAN
G2 Provider Commercial #
ZZ Taxonomy Code

LAST: Enter the operating physicians last name

FIRST: Enter the operating physicians first name.

Enter the Provider Type qualifier, NPI, and Name of the
physician in charge of the patient care:
(Blank Field): Enter one of the following Provider Type
Qualifiers:
DN Referring Provider
ZZ Other Operating MD
82 Rendering Provider

NPI: Enter the other physician 10-character NPI ID.

78 & 79 OTHER PHYSICIAN C
QUAL: Enter one of the following qualifier and ID number
0B State License #
1G Provider UPIN
G2 Provider Commercial #

LAST: Enter the other physicians last name.

FIRST: Enter the other physicians first name.

80 REMARKS Not Required

81 CC A: Taxonomy of billing provider. Use ZZ qualifier R