UB-04 Claim Form and Instructions F A

The UB-04 claim form, also known as the CMS-1450 form, is approved by the Centers for Medicare & Medicaid Services (CMS) and the
National Uniform Billing Committee for facility and ancillary paper billing. Sample UB-04 forms for inpatient and outpatient claims can be
found on pages 4 and 5.
If you have any questions regarding the UB-04 claim form, please call your Network Coordinator or contact Customer Service at 1-888-YOUR-AH1
(1-888-968-7241).

UB-04 data field requirements

Field location UB-04 Description Inpatient Outpatient
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
Revenue Code Description Required Required
43
NDC Code Required, if applicable Required, if applicable
UB-04 Claims Submission Guide

Field location UB-04 Description Inpatient Outpatient

44 HCPCS/Rates Required, if applicable Required, if applicable
45 Service Date N/A Required
46 Units of Service Required Required
47 Total Charges (By Rev. Code) Required Required
48 Non-Covered Charges Required, if applicable Required, if applicable
49 Future Use N/A N/A
50 Payer Name Required Required
51 Health Plan ID Situational Situational
52 Release of Information Certification Required Required
53 Assignment of Benefit Certification Required Required
54 Prior Payments Required, if applicable Required, if applicable
55 Estimated Amount Due Required Required
56 NPI Required Required
57 Other Provider IDs Optional Optional
58 Insured’s Name Required Required
59 Patient’s Relation to the Insured Required Required
60 Insured’s Unique ID Required Required
61 Insured’s Group Name Situational Situational
62 Insured’s Group Number Situational Situational
63 Treatment Authorization Codes Required, if applicable Required, if applicable
64 Document Control Number Situational Situational
65 Employer Name Situational Situational
66 Diagnosis/Procedure Code Qualifier Required Required
67 Principal Diagnosis Code/Other Diagnosis Required Required
Codes
68 Future Use N/A N/A
69 Admitting Diagnosis Code Required Required, if applicable
70 Patient’s Reason for Visit Code N/A Situational
71 PPS Code Situational Situational
72 External Cause of Injury Code Situational Situational
73 Future Use N/A N/A
74 Principal Procedure Code/Date Required, if applicable N/A
75 Future Use N/A N/A
76 Attending Provider Name/NPI Required Required
77 Operating Physician Name/NPI Situational Situational
78-79 Other Provider Name/NPI Situational Situational
80 Remarks Situational Situational
Code-Code Field/Qualifiers
N/A N/A
0-A0
A1-A4 Situational Situational
A5-AB N/A N/A
81
AC - Attachment Control number Situational Situational
AD-B0 N/A N/A
B1-B2 Situational Situational
B3 Taxonomy Code Qualifier Required Required
 UB-04 Claims Submission Guide

Readability Requirements
To ensure that all claims are processed against the same requirements, paper claims are converted to an electronic format. However,
system limitations can cause data elements to be misinterpreted during the conversion process. Follow these guidelines to ensure your
claims are successfully converted:

DO DON’T
• Use red drop on UB-04 paper forms only. • Do not include handwriting anywhere on the claim form.
• Replacement/corrected claims require a Type of Bill with • Do not use stamped data in any field (NPI, provider
a Frequency Code “7” (field 4) and claim number in the names, signatures, corrections, etc.).
Document Control Number (field 64). • Do not print claim data out of the designated field; it may
• Enter all required data. not be captured.
• All patient details are required (ID number with prefix, • Do not print from an older DOT matrix printer; it may not
last name, first name, and date of birth). be captured.
• Separate the subscriber/patient last name and first name
with a comma.
• Ensure the use of proper coding (ICD-10 HIPAA codes,
dates of service, and correcting a prior claim).
• Use standard fonts and sizes.
UB-04 Claims Submission Guide

INPATIENT
UB-04 Claim Form and Instructions

OUTPATIENT

© 2019 AmeriHealth | 18080 | 2019 August

AmeriHealth Insurance Company of New Jersey | AmeriHealth HMO, Inc.