2014 Data Specifications Manual OFFICIAL ADOPTED BY:

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].
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Single User License
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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
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Version 8.00 July 2013
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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
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State Guidelines
Florida
Minnesota
North Carolina
South Carolina
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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
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Version 8.00 July 2013
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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
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