Ub 04 Form - Tricare Bill Form
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1
2__
__
__
4
TYPE
3a PAT.
1
2
OF BILL
CNTL #
b. MED.
REC. #
6
7
STATEMENT COVERS PERIOD
5 FED. TAX NO.
FROM
THROUGH
8 PATIENT NAME
9 PATIENT ADDRESS
a
a
b
b
c
d
e
ADMISSION
CONDITION CODES
29 ACDT 30
10 BIRTHDATE
11 SEX
16 DHR
17 STAT
12
13 HR 14 TYPE 15 SRC
18
19
20
21
22
23
24
25
26
27
28
DATE
STATE
31
OCCURRENCE
32
OCCURRENCE
33
OCCURRENCE
34
OCCURRENCE
35
OCCURRENCE SPAN
36
OCCURRENCE SPAN
37
CODE
DATE
CODE
DATE
CODE
DATE
CODE
DATE
CODE
FROM
THROUGH
CODE
FROM
THROUGH
a
a
b
b
38
39
40
41
VALUE CODES
VALUE CODES
VALUE CODES
CODE
AMOUNT
CODE
AMOUNT
CODE
AMOUNT
a
b
c
d
42 REV. CD.
43 DESCRIPTION
44 HCPCS / RATE / HIPPS CODE
45 SERV. DATE
46 SERV. UNITS
47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
PAGE
OF
CREATION DATE
TOTALS
23
23
52 REL
.
53 ASG.
50 PAYER NAME
51 HEALTH PLAN ID
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56 NPI
INFO
BEN.
A
A
57
B
OTHER
B
PRV ID
C
C
58 INSURED’S NAME
59 P . REL 60 INSURED’S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
A
A
B
B
C
C
67
A
B
C
D
E
F
G
H
66
68
DX
I
J
K
L
M
N
O
P
Q
a
b
c
a
b
c
69 ADMIT
70 PATIENT
71 PPS
72
73
DX
REASON DX
CODE
ECI
74
PRINCIPAL PROCEDURE
a.
OTHER PROCEDURE
b.
OTHER PROCEDURE
75
QUAL
76 ATTENDING
NPI
CODE
DATE
CODE
DATE
CODE
DATE
LAST
FIRST
c.
OTHER PROCEDURE
d.
OTHER PROCEDURE
e.
OTHER PROCEDURE
QUAL
77 OPERATING
NPI
CODE
DATE
CODE
DATE
CODE
DATE
LAST
FIRST
81CC
80 REMARKS
78 OTHER
NPI
QUAL
a
b
LAST
FIRST
c
79 OTHER
NPI
QUAL
d
LAST
FIRST
UB-04 CMS-1450
APPROVED OMB NO. 0938-0997
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
NUBC
™
National Uniform
Billing Committee
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