OFFICIAL
Data Specifications Manual
2014
VERSION 8.00 | JULY 2013
ADOPTED BY:
© Copyright 2013 American Hospital Association (AHA). All Rights reserved.
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2014
COPYRIGHT NOTICE
The Official UB-04 Data Specifications Manual (the “UB-04 Manual”) is protected under federal
copyright laws and owned by the American Hospital Association. When you purchased a copy
of the UB-04 Manual, the American Hospital Association granted to you a single, individual
user, nontransferable and nonexclusive license to use this copy of the UB-04 Manual. Under this
single-user license, you may print one hard copy, but cannot share or redistribute this electronic
file.
If other individuals at your organization or entity require access to the UB-04 Manual, you are
required to purchase additional copies or obtain a license permitting use by multiple individuals
in one single entity. Making copies of the UB-04 Manual or any portion thereof for internal
purposes (beyond the one allowed copy as noted above), resale and/or to be licensed in any
product or publication; creating any modified or derivative work of the UB-04 Manual; and/or
making any commercial use of UB-04 Manual or any portion thereof is only authorized with an
express license from the American Hospital Association. To inquire about licensing
arrangements, please contact Tim Carlson at (866) 375-3633 or [email protected].
AHA © 2013
Single User License
Please do not copy or distribute
Version 8.00 July 2013
Page 2 of 292
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2014
2014 Table of Contents
Introduction
Form Locators
FL 01 - Billing Provider Name, Address and Telephone Number
FL 02 - Billing Provider’s Designated Pay-to Address
FL 03a - Patient Control Number
FL 03b - Medical/Health Record Number
FL 04 - Type of Bill
FL 05 - Federal Tax Number
FL 06 - Statement Covers Period (From - Through)
FL 07 - Reserved for Assignment by the NUBC
FL 08 - Patient Name/Identifier
FL 09 - Patient Address
FL 10 - Patient Birth Date
FL 11 - Patient Sex
FL 12 - Admission/Start of Care Date
FL 13 - Admission Hour
FL 14 - Priority (Type) of Admission or Visit
FL 15 - Point of Origin for Admission or Visit
FL 16 - Discharge Hour
FL 17 - Patient Discharge Status
FL 18-28 - Condition Codes
FL 29 - Accident State
FL 30 - Reserved for Assignment by the NUBC
FL 31-34 - Occurrence Codes and Dates
FL 35-36 - Occurrence Span Codes and Dates
FL 37 - Reserved for Assignment by the NUBC
FL 38 - Responsible Party Name and Address (Claim Addressee)
FL 39-41 - Value Codes and Amounts
FL 42 - Revenue Codes
FL 43 - Revenue Description/IDE Number/Medicaid Drug Rebate
FL 44 - HCPCS/Accommodation Rates/HIPPS Rate Codes
FL 45 - Service Date
FL 46 - Service Units
FL 47 - Total Charges
FL 48 - Non-covered Charges
FL 49 - Reserved for Assignment by the NUBC
FL 50 - Payer Name
FL 51 - Health Plan Identification Number
FL 52 - Release of Information Certification Indicator
FL 53 - Assignment of Benefits Certification Indicator
FL 54 - Prior Payments - Payer
FL 55 - Estimated Amount Due - Payer
FL 56 - National Provider Identifier - Billing Provider
FL 57 - Other (Billing) Provider Identifier
FL 58 - Insured’s Name
FL 59 - Patient’s Relationship to Insured
FL 60 - Insured’s Unique Identifier
AHA © 2013
Single User License
Please do not copy or distribute
Page 1 of 2
5
10
12
13
14
15
24
25
28
29
31
32
33
34
35
36
37
44
45
61
75
76
77
85
89
90
91
108
167
169
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
Version 8.00 July 2013
Page 3 of 292
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2014
2014 Table of Contents
Page 2 of 2
Form Locators
FL 61 - Insured’s Group Name
FL 62 - Insured’s Group Number
FL 63 - Authorization Code/Referral Number
FL 64 - Document Control Number (DCN)
FL 65 - Employer Name (of the Insured)
FL 66 - Diagnosis and Procedure Code Qualifier (ICD Version Indicator)
FL 67 - Principal Diagnosis Code and Present on Admission Indicator
FL 67A-Q - Other Diagnosis Codes and Present on Admission Indicator
FL 68 - Reserved for Assignment by the NUBC
FL 69 - Admitting Diagnosis Code
FL 70a-c - Patient’s Reason for Visit
FL 71 - Prospective Payment System (PPS) Code
FL 72a-c - External Cause of Injury (ECI) Code and POA Indicator
FL 73 - Reserved for Assignment by the NUBC
FL 74 - Principal Procedure Code and Date
FL 74a-e - Other Procedure Codes and Dates
FL 75 - Reserved for Assignment by the NUBC
FL 76 - Attending Provider Name and Identifiers
FL 77 - Operating Physician Name and Identifiers
FL 78-79 - Other Provider Name and Identifiers
FL 80 - Remarks Field
FL 81 - Code-Code Field
187
188
189
190
191
192
196
201
202
203
204
205
206
207
208
209
210
211
213
215
217
218
State Guidelines
Florida
Minnesota
North Carolina
South Carolina
224
235
238
240
Appendix
UB-92 to UB-04 Crosswalk
UB-04 Mapping to 837 Claim Transaction (4010A1)
UB-04 Mapping to 837 Claim Transaction (5010)
UB-04/837 Reporting Differences
Change Log
UB-04 Form (front)
Back of UB-04 Form (For Informational Purposes Only)
UB-04/CMS-1450 Printing Specifications
245
253
269
284
285
288
289
290
AHA © 2013
Single User License
Please do not copy or distribute
Version 8.00 July 2013
Page 4 of 292
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2014
Effective Date: March 1, 2007
Meeting Date:
Form Locator 01
Page 1 of 2
Data
Element
Billing Provider Name, Address and Telephone Number
Definition:
The name and service location of the provider submitting the bill.
Reporting
Name and Address
• UB-04: Required.
• 004010/004010A1: Required.
• 005010: Required.
Telephone
• UB-04: Required.
• 004010/004010A1: Situational. Required when this information is different
than that contained in the Submitter PER segment (Loop ID-1000A).
• 005010: Situational. Required when this information is different than that
contained in the Submitter PER segment (Loop ID-1000A).
Country Code
• UB-04: Situational. Required when the address is outside the United States of
America.
• 004010/004010A1: Situational. Required when the address is outside of the
U.S.
• 005010: Situational. Required when the address is outside the United States of
America.
Field
Attributes
1 Field
4 lines
25 Positions
Alphanumeric
Left-justified
AHA © 2013
Single User License
Please do not copy or distribute
Version 8.00 July 2013
Page 10 of 292