UB04s PDF Template

[toc] When an institutional provider needs to bill mental health and medical claims, they use the UB-04. This form is a uniform billing form that most practices use as their standard claim form. It was originally developed through CMS (Centers for Medicare and Medicaid), but since then has expanded to be used by the majority of insurance carriers.

UB-04 forms, otherwise known as uniform billing forms, are standard claim forms that institutional providers use. All insurance carriers who bill for mental health and medical reasons will do so through the UB-04. The form is designed and modified through the American Hospital Association and National Uniform Billing Committee. These organizations also publish a UB-04 manual for easier use.

If you want to make sure the form is filled out completely and accurately, you should make sure of the following:

You have the required data from each insurance payer

All the data has been entered accurately in the right fields

Insurance information has been entered exactly the way it appears on the patient’s insurance card

Procedure codes and diagnosis codes are correctly used, as are modifiers when they’re required

Only the physical address has been used for the service facility’s location

NPI (National Provider Identifier) information has been included where necessary

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Institutional providers who need to bill medical claims can use the UB-04 form to do so. This includes, but isn’t limited to:

Mental health centers and offices

Rehabilitation facilities

Hospitals

Laboratories

Physical therapy services

Organ procurement organizations

Speech pathology services

Skilled nursing facilities

Rural health clinics

The UB-04 form is a standard form used for universal billing. When an institutional provider needs to bill a patient or their insurance company, this is the form that should be used. It should be noted that the UB-04 form is only meant to be used in cases regarding medical bills and bills for mental healthcare. For other types of bills, there are other universal billing forms instead.

The point of the UB-04 form is to streamline and standardize the billing process. There’s no reason not to use it for your billing. You can go off-book and create your own type of billing, but you’ll need to make sure you collect all the same information listed in the UB-04 form anyway. It makes more sense to just use the universal billing form. This is especially true given that the UB-04 form is constantly being updated and contains an additional manual.

The UB-04 form contains 81 input fields. These are colloquially called “form locators,” otherwise abbreviated as FL. Each serves its own unique purpose.

In the first FL, you’ll give the billing provider’s name, along with their street address and contact information. If the pay-to name is different from this, you’ll note it in the second FL.

Use Box 3 to indicate your patient control number along with your facility’s medical record number. Box 4 indicates the type of bill. You’ll need to use the four-digit code that adheres to the guidelines set out by the National Uniform Billing Committee. Box 5 asks for your facility’s federal tax number.

Box 6 will ask you to denote what dates the claim’s service happened. You should write them in MM-DD-YY format. Boxes 8 through 11 take down basic information about the patient. Boxes 12 through 17 ask for details about their admission and stay. For boxes 18 through 28, you’ll need to use two-digit universal billing codes found in the manual to describe conditions.

Boxes 31 through 36 ask for more codes found in the universal billing manual. When you get to Box 38, you’ll need to give the name and address of the responsible party. For Boxes 39 through 44, you’ll need to provide more codes. Boxes 45 through 48 include the service dates, total charges, and any charges that aren’t covered.

Use the codes provided for Boxes 50 through 65 to make notes about the basic billing. Boxes 66 through 72 will use more codes, including diagnosis codes, reason for visit codes, and PPS code.

When you fill out Boxes 76 through 79, you’ll need information about the attending provider, operating physician, and any other providers involved. These include the first and last name of the personnel, their qualifiers, their ID, and their NPI.

Box 80 is reserved for remarks. You’ll use it if you need to make any additional notations, or if a field that requires remarks is full before you finish writing. The final box, Box 81, is the taxonomy code along with a qualifier.[pdf-embedder url=”https://cdn-prod-pdfsimpli-wpcontent.azureedge.net/pdfseoforms/pdf-20180219t134432z-001/pdf/ub04-forms.pdf”]