Ub-04 Claim Form And Instructions

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UB-04 claim form and instructions
The Office of Management and Budget and the National Uniform Billing Committee have approved the
UB-04 claim form, also known as the CMS-1450 form. The UB-04 claim form accommodates the National
Provider Identifier (NPI) and has incorporated other important changes. Sample UB-04 forms for inpatient
and outpatient claims can be found on pages 3 and 4.
The UB-04 claim form and NPI
The UB-04 claim form includes several fields that accommodate the use of your NPI. Although the form
accommodates the NPI, you may continue to report your current provider identification numbers in the
appropriate areas of the form until otherwise notified. If you have obtained your NPIs and submitted them to
us, you must report them on the UB-04 claim form.
If you have any questions regarding the UB-04 claim form, the NPI application process, or reporting your NPI
to us, please call your Network Coordinator or contact Customer Service at 1-800-ASK-BLUE.
UB-04 data field requirements
Field location
Description
Inpatient
Outpatient
UB-04
1
Provider Name and Address
Required
Required
2
Pay-To Name and Address
Situational
Situational
3a
Patient Control Number
Required
Required
3b
Medical Record Number
Situational
Situational
4
Type of Bill
Required
Required
5
Federal Tax Number
Required
Required
6
Statement Covers Period
Required
Required
7
Future Use
N/A
N/A
8a
Patient ID
Situational
Situational
8b
Patient Name
Required
Required
9
Patient Address
Required
Required
10
Patient Birthdate
Required
Required
11
Patient Sex
Required
Required
12
Admission Date
Required
Required, if applicable
13
Admission Hour
Required
Required, if applicable
14
Type of Admission/Visit
Required
Required
15
Source of Admission
Required
Required
16
Discharge Hour
Required
N/A
17
Patient Discharge Status
Required
Required
18-28
Condition Codes
Required, if applicable
Required, if applicable
29
Accident State
Situational
Situational
30
Future Use
N/A
N/A
31-34
Occurrence Codes and Dates
Required, if applicable
Required, if applicable
35-36
Occurrence Span Codes and Dates
Required, if applicable
Required, if applicable
37
Future Use
N/A
N/A
38
Responsible Party Name and Address
Required, if applicable
Required, if applicable
39-41
Value Codes and Amounts
Required, if applicable
Required, if applicable
42
Revenue Code
Required
Required
43
Revenue Code Description
Required
Required
NDC Code
Required, if applicable
Required, if applicable
1
Independence Blue Cross offers products directly, through its subsidiaries Keystone
Health Plan East and QCC Insurance Company, and with Highmark Blue Shield —
12.09
independent licensees of the Blue Cross and Blue Shield Association.

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