UB 04 Form instruction

There are totally 81 Fields.

Form Locator (FL) 1 - (Untitled) Provider Name, Address, and Telephone Number

Required. The minimum entry is the provider name, city, State, and ZIP code. The post
office box number or street name and number may be included. The State may be
abbreviated using standard post office abbreviations. Five or nine-digit ZIP codes are
acceptable. This information is used in connection with the Medicare provider number
(FL 51) to verify provider identity. Phone and/or Fax numbers are desirable.

FL 2 – Pay-to Name, address, and Secondary Identification Fields

Required when the pay-to name and address information is different than
the Billing Provider information in FL1. If used, the minimum entry is the provider
name, address, city, State, and ZIP code.

FL 3a - Patient Control Number

Required. The patient’s unique alpha-numeric control number assigned by the provider
to facilitate retrieval of individual financial records and posting payment may be shown
if the provider assigns one and needs it for association and reference purposes.

FL 3b – Medical/Health Record Number

Situational. The number assigned to the patient’s medical/health record by the provider
(not FL3a).

FL 4 - Type of Bill

Required. This four-digit alphanumeric code gives three specific pieces of information
after a leading zero. CMS will ignore the leading zero. CMS will continue to process
three specific pieces of information. The second digit identifies the type of facility. The
third classifies the type of care. The fourth indicates the sequence of this bill in thisparticular episode of care. It is referred to as a “frequency” code.

FL 5 - Federal Tax Number

Required. The format is NN-NNNNNNN.

FL 6 - Statement Covers Period (From-Through)

Required. The provider enters the beginning and ending dates of the period included onthis bill in numeric fields (MMDDYY). Days before the patient’s entitlement are notshown. With the exception of home health PPS claims, the period may not span twoaccounting years. The FI uses the “From” date to determine timely filing.

FL 7

Not Used.

FL 8 - Patient’s Name

Required. The provider enters the patient’s last name, first name, and, if any, middleinitial, along with patient ID (if different than the subscriber/insured’s ID).

FL 9 Patient address

Required. The provider enters the patient’s full mailing address, including street numberand name, post office box number or RFD, city, State, and Zip code.

FL 10 - Patient’s Birth Date

Required. The provider enters the month, day, and year of birth (MMDDCCYY) ofpatient. If full birth date is unknown, indicate zeros for all eight digits.

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