UB 04 or CMS 1450 FORM
UB 04 claim form also known as CMS 1450 is used by hospitals, nursing facilities, and inpatient and other facility providers. It contains 81 Locaters and below are the details of each box of UB 04 form,
Locator# Inpatient Outpatient Description
1 Required Required Billing Provider Name and Address
2 Optional Optional Billing Pay-To Name and Address, if it is different from
field 1
3a Required Required Patient Control Number
3b Optional Optional Medical Record Number
4 Required Required Type of Bill
5 Required Required Federal Tax Number
6 Required Required Statement Covers Period
7 NA NA Not in use
8a Optional Optional Patient ID
8b Required Required Patient Name
9 Required Required Patient Address
10 Required Required Patient Birthdate
11 Required Required Patient Sex
12 Required Required, Admission Date
if applicable
13 Required Required, Admission Hour
if applicable
14 Required Required Type of Admission/Visit
15 Required Required Source of Admission
16 Required NA Discharge Hour
17 Required Required Patient Discharge Status
18-28 Required, Required, Condition Codes
if applicable if applicable
29 Optional Optional Accident State
30 NA NA Not in use
31-34 Required, Required, Occurrence Codes and Dates
if applicable if applicable
35-36 Required, Required, Occurrence Span Codes and Dates
if applicable if applicable
37 NA NA Not in use
38 Required, Required, Responsible Party Name and Address
if applicable if applicable
39-41 Required, Required, Value Codes and Amounts
if applicable if applicable
42 Required Required Revenue Code
43 Required Required Revenue Code Description
Required, Required, NDC Code (This is applicable drug code)
if applicable if applicable
44 Required, Required, HCPCS/Rates
if applicable if applicable
45 NA Required Service Date
46 Required Required Units of Service
47 Required Required Total Charges
48 Required, Required, Non-Covered Charges
if applicable if applicable
49 NA NA Not in use
50 Required Required Payer Identification (Name)
51 Optional Optional Health Plan Identification Number
52 Required Required Release of Info Certification
53 Required Required Assignment of Benefit Certification
54 Required, Required, Prior Payments
if applicable if applicable
55 Required Required Estimated Amount Due
56 Required Required Billing Provider NPI
57 Optional Optional Other Provider IDs
58 Required Required Insured’s Name
59 Required Required Patient’s Relation to the Insured
60 Required Required Insured’s Unique ID
61 Optional Optional Insured Group Name
62 Optional Optional Insured Group Number
63 Required, Required, Treatment Authorization Codes
if applicable if applicable
64 Optional Optional Document Control Number
65 Optional Optional Employer Name
66 Required, Required, Diagnosis/Procedure Code Qualifier
if applicable if applicable
67 Required Required Principal Diagnosis Code
67 A-Q Optional Optional Other Diagnosis Code
68 NA NA Not in use
69 Required Required, Admitting Diagnosis Code
if applicable
70 Optional Optional Patient’s Reason for Visit Code
71 Optional Optional Prospective Payment System Code
72 Optional Optional External Cause of Injury Code
73 NA NA Not in use
74 Required, Required, Principal Procedure Code & Date
if applicable if applicable
74 A-E Optional Optional Other Procedure Codes & Date
75 NA NA Not in use
76 Required Required Attending provider name, ID, qualifiers, lats & first
name
77 Optional Optional Operating physician name, ID, qualifiers, lats & first
name
78-79 Optional Optional Other provider name, ID, qualifiers, lats & first
name
80 Optional Optional Remarks
81 Optional Optional Taxonomy code and qualifier
In the qualifier field of locator 81, the value will be B3 if locators 76-79 contain an NPI. Based on available providers in locators 76-79, the taxonomy code needs to be entered in locators 81cc a - 81cc d. For example, if provider information is available in locator 76 then the taxonomy code of that provider needs to be entered in 81cc a. If provider information is available in locator 77 then the taxonomy code needs to be entered in 81cc b. Similarly, for 78 into 81cc c & for 79 into 81cc d.
very accurate
ReplyDeleteThanks!
Delete