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Medical UB-04 Claim Form

The UB04 claimform is typically used for institutional claims and is included in Version 12.0.  The claim forms are printed; they are not sent in e-claims. 

Printing
If you are using the UB-04 claimform, it is helpful to have a background image for setup puposes.  The background image should not print because preprinted forms should be used.  To see the background, save the file UB04.jpg in your A to Z folder, then add it to the Claim Form.

UB04 Information
Information specific to the UB04 Claim Form is entered on the Edit Claim window under the Medical UB-04 tab. Check with the insurance company to verify the values they accept for each of the values in this section.

Type of Bill (3 digit): Enter a three-digit code using the table below.

Code Description
1st Digit – Type of Facility
1 Hospital
2 Skilled Nursing Facility
3 Home Health>
4 Christian Science (Hospital)
5 Christian Science (Extended Care)
6 Intermediate Care
7 Clinic
2nd Digit – Bill Classifications
(Excluding Clinics & Special Facilities)
1 Inpatient
3 Outpatient
4 Other (For Hospital Referenced Diagnostic Services, or Home Health Not Under a Plan of Treatment)
5 Intermediate Care, Level I
6 Intermediate Care, Level II
7 Intermediate Care, Level III
8 Swing Beds
(Clinics Only)
1 Rural Health
2 Hospital Based or Independent Renal Dialysis Center
3 Free Standing
4 Other Rehabilitation Facility (ORF)
9 Other
(Special Facility Only)
1 Hospice (Non-Hospital Based)
2 Hospice (Hospital Based)
3 Ambulatory Surgery Center (ASC)
4 Freestanding Birthing Center
3rd Digit – Frequency
1 Admit through Discharge Claim
2 Interim – First Claim
3 Interim – Continuing Claims
4 Interim – Last Claim
5 Late Charge only
6 Adjustment of Prior Claim
7 Replacement of Prior Claim
8 Void/Cancel of Prior Claim

Admission Type:  1-Emergency, 2-Urgent, 3-Elective, 4-Newborn, 5-Trauma Center, 6-8 Reserved, 9-Information Not Available.

Admission Source:

Code Description
Except Newborns (Field 20)
1 Physician Referral
2 Clinic Referral
3 HMO Referral
4 Transfer from a Hospital
5 Transfer from a Skilled Nursing Facility (SNF)
6 Transfer from Another Health Facility
7 Emergency Room
8 Court/Law Enforcement
9 Information Not Available
10 Transfer from Psych Substance Abuse or Rehab Hospital
11 Transfer from a Critical Access Hospital
Additional Source of Admission Codes for Newborns (Field 20)
1 Normal Delivery
2 Premature Delivery
3 Sick Baby
4 Extramural Birth
5 Information Not Available

Patient Status:

Code Definition
01 Discharged to Home or Self-Care (Routine Discharge)
02 Discharged/Transferred to Another Short-Term General Hospital
03 Discharged/Transferred to an SNF
04 Discharged/Transferred to an Intermediate Care Facility (ICF)
05 Discharged/Transferred to Another Type of Institution (Including Distinct Parts) or Referred for Outpatient Services to Another Institution
06 Discharged/Transferred to Home Under Care of Organized Home Health Service Organization
07 Left Against Medical Advise or Discontinued Care
08 Discharged/Transferred to Home Under Care of Home IV Therapy Provider
09 Admitted as an Inpatient to this Hospita
20 Expired (or Did Not Recover-Christian Science Patient)
30 Still a Patient or Expected to Return for Outpatient Services
31 – 39 Still Patient to be Defined at State Level, if Necessary
40 Expired at Home (for Hospice Care Only)
41 Expired in a Medical Facility such as a Hospital, SNF, ICF or Freestanding Hospice (for Hospice Care Only)
42 Expired, Place Unknown (for Hospice Care Only)
50 Discharged to Hospice-Home
51 Discharged to Hospice-Medical Facility

Condition Codes:  Use this condition code:

If the admission/service was:
C1 Approved as billed
C2 Automatically approval as billed based on focused review
C3 Partially approval
C4 Denied
C5 Is post-payment review applicable
C6 Required admission pre-authorization
C7 Had extended authorization (was authorized for an extended length of time, but the services provided have not been reviewed)
If the reason for the claim change is:
D0 Changes to service dates
D1 Changes to charges
D2 Changes in revenue codes/HCPCS/HIPPS rate codes
D3 Second or subsequent interim prospective payment system (PPS) bill
D4 Changes in ICD-9-CM diagnosis and/or procedure codes
D5 Cancel to correct health insurance claim number (HICN) or provider identification number
D6 Cancel only to repay a duplicate or Office of Inspector General (OIG) overpayment
D7 Change to make Medicare the secondary payer
D8 Change to make Medicare the primary payer
D9 Any other change
E0 Change in patient status
G0 Distinct medical visit
H0 Delayed filing, statement of intent submitted
H2 Discharge by a hospice provider for cause
W2 Duplicate of original bill
W3 Level I appeal
W4 Level II appeal
W5 Level III appeal


Value Codes: Use these codes.

If you are submitting a claim for:
01 Most common semi-private room rate
02 Hospital has no semi-private rooms
04 Professional component charges, which are combined billed
05 Professional component included in charges and also billed separately to carrier
06 Medicare blood deductible
08 Medicare lifetime reserve amount (in the first calendar year)
09 Medicare co-insurance amount (in the first calendar year in billing period)
10 Medicare lifetime reserve amount (in the second calendar year)
11 Medicare co-insurance amount (in the second calendar year)
12 A working-aged beneficiary/spouse with employer group health plan
13 An end-stage renal disease (ESRD) beneficiary in a Medicare coordination period with an employer group health plan
14 No fault, including auto/other
15 Workers’ compensation
16 Public Health Service or other federal agency
30 Pre-admission testing
31 Patient liability amount
32 Multiple patient ambulance transport
37 Units of blood furnished
38 Blood deductible units
39 Pints of blood replaced
40 New coverage not implemented by HMO (for inpatient claims only)
41 Black lung
42 Veteran’s Affairs
43 Disabled beneficiary under age 65 with large group health plan
44 Amount provider agreed to accept from the primary insurer when this amount is less than charges but greater than the primary insurer’s payment
45 Accident hour*
46 Number of grace days
47 Any liability insurance
48 Hemoglobin reading
49 Hematocrit reading
50 Physical therapy visits
51 Occupational therapy visits
52 Speech therapy visits
53 Cardiac rehabilitation visits
54 Newborn birth weight in grams
55 Eligibility threshold for charity care
56 Skilled nurse – home visit hours (HHA only)
57 Home health aide – home visit hours (HHA only)
58 Arterial blood gas (PO2/PA2)
59 Oxygen saturation
60 Home Health Agency branch MSA
61 Place of residence where service is furnished (home health aide and hospice)
66 Medicaid spend down amount
67 Peritoneal dialysis
68 Epoetin Alfa (EPO) – drug
69 State charity care precert
80 Covered days
81 Non-covered days
82 Co-insurance days
83 Lifetime reserve days
A0 Special zip code reporting
A1 Deductible payer A
B1 Deductible payer B
C1 Deductible payer C
E1 Deductible payer D; discontinued 3/1/07
F1 Deductible payer E; discontinued 3/1/07
G1 Deductible payer F; discontinued 3/1/07
A2 Co-insurance payer A
B2 Co-insurance payer B
C2 Co-insurance payer C
E2 Co-insurance payer D
F2** Co-insurance payer E; code discontinued 3/1/07
G2** Co-insurance payer F; discontinued 3/1/07
A3 Estimated responsibility payer A
B3 Estimated responsibility payer B
C3 Estimated responsibility payer C
D3 Estimated responsibility patient
D4 Clinical trial number assigned by National Library of Medicine (NLM)/National Institutes of Health (NIH)
E3 Discontinued, effective with UB-04 implementation 3/1/07
F3 Discontinued, effective with UB-04 implementation 3/1/07
G3 Discontinued, effective with UB-04 implementation 3/1/07
A4 Covered self-administrable drugs–emergency
A5 Covered self-administrable drugs not self-administrable in form and situation furnished to patient
A6 Covered self-administrable drugs–diagnostic study and other
A7 Copayment payer A; this code is used only on paper claims; for electronic 837 claim, use Loop ID 2320 CAS segment (Claim Adjustment Group Code “PR”).
B7 Copayment payer B; this code is used only on paper claims; for electronic 837 claim, use Loop ID 2320 CAS segment (Claim Adjustment Group Code “PR”).
C7 Copayment payer C; this code is used only on paper claims; for electronic 837 claim, use Loop ID 2320 CAS segment (Claim Adjustment Group Code “PR”).
E7 Copayment payer E; discontinued 3/1/07
F7 Copayment payer F; discontinued 3/1/07
G7 Copayment payer G; discontinued 3/1/07
G8 MSA or Core-Based Statistical Area (CBSA) number (or rural state code) of the facility where inpatient hospice service is delivered. Report the number in dollar portion of the form locator right-justified to the left of the dollar/cents delimiter.
**For Medicare, use this code only for reporting Part B co-insurance amounts.


 

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