UB-04 Billing Claim Form, also known as the
CMS-1450 Form, used for facility and ancillary paper billing. Approved by the Centers for Medicare & Medicaid Services (CMS) and the National Uniform Billing Committee (NUBC).
COMPLETING THE UB-04 CLAIM FORM
There are 81 fields on a Uniform Bill (UB-04) – Form CMS-1450. Each field is referred to as form locators or “FL”. Each form locator is designated for a unique purpose. This form can be used for billing multiple third party payers. Because it serves many payers, a particular payer may not need some data elements. For more information on the UB-04 billing form or to purchase the UB-04 Data Specifications Manual, visit the National Uniform Billing Committee (NUBC) Web site.
FL 5 – Federal Tax Number
Required. Used to identify the facility or provider by the federal government for tax reporting purposes. Also known as a tax identification number (TIN) or employer identification number (EIN). The format is NN-NNNNNNN.
FL 6 – Statement Covers Period
Required. Enter the beginning and ending service dates for inpatient/outpatient claims identified on this bill. The “From” date should not be confused with the Admission Date. For all services received on a single day, use the same date for “From” and “Through”. Enter the date as month, day, and year (MMDDYY).
FL 7 – Not Used
Not Used. Reserved for assignment by the NUBC.
FL 8 – Patient’s Name and Identifier
8a – Situational. Enter the patient’s ID if different than field locator 60 (Insured’s Unique Identifier). 8b Required. Enter the patient’s last name, first name, and, if any, middle initial, using the Last, First name, MI format. Patient’s name should be entered as shown on Medicare card. Do not use nicknames or abbreviated names.
FL 9 – Patient’s Address
Required. Enter the patient’s full mailing address and country code if applicable to the claim.
9a – Patient’s Street Address
9b – Patient’s City
9c – Patient’s State
9d – Patient’s Zip
9e – Situational. Patient’s Country Code – Only used if patient is from outside the United States