Facility & Billing Information (Fields 1\u20136)<\/strong><\/h3>\n\n\n\nThis section of the CMS-1450 form identifies the nature of the medical claim. It covers details such as the provider’s name, address, NPI, and the type of bill.<\/p>\n\n\n\nField Locator<\/strong><\/th>Field Details<\/strong><\/th>How To Fill It?<\/strong><\/th><\/tr><\/thead>FL 1<\/td> Provider name, address<\/td> Write the facility’s legal name, full physical address, and telephone number.<\/td><\/tr> FL 2<\/td> Pay-to-name, address<\/td> State the name and address to which payment should be sent. (optional)<\/td><\/tr> FL 3a<\/td> Patient control number <\/td> Unique ID assigned by your practice management system for internal tracking.<\/td><\/tr> FL 3b<\/td> Patient\u2019s medical record number<\/td> Enter the patient\u2019s permanent ID for tracking.<\/td><\/tr> FL4<\/td> Type of Bill<\/td> Mention the 4-digit code. <\/td><\/tr> FL 5<\/td> Tax ID<\/td> Enter the facility\u2019s federal tax ID (EIN).<\/td><\/tr> FL 6<\/td> Statement Covers Period<\/td> Provide the beginning and ending service dates for the period covered on the claim.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\nWhat Are Bill Types for UB-04?<\/strong><\/h4>\n\n\n\nIt is the field locator 4 in the UB-04 claim form. A 4-digit number that offers the payer the following information:<\/p>\n\n\n\n
\nWhere did the service take place?<\/li>\n\n\n\n What kind of care was it?<\/li>\n\n\n\n What was the sequence of the claim?<\/li>\n<\/ul>\n\n\n\n1st Digit<\/strong><\/th>2nd Digit<\/strong><\/th>3rd Digit<\/strong><\/strong><\/th>4th Digit<\/strong><\/th><\/tr><\/thead>It is always a \u2018zero\u2019.<\/td> It specifies the type of facility. For example, 1 = Hospital, 2 = SNF, 3 = Home health, etc.<\/td> It identifies the type of care. For example, 1 = Inpatient (part A), 3 = Outpatient, etc.<\/td> It indicates the sequence of the bill. For example, 0 = Non-payment\/zero claim, 1 = Admit through discharge, etc.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\nPatient Demographics & Admission (Fields 7\u201317)<\/strong><\/h3>\n\n\n\nThese fields of the UB-04 claim form require you to provide details about the patient’s identity and the clinical specifics of their arrival. These include the date, hour, and priority of their admission through to their final discharge status.<\/p>\n\n\n\nField Locator<\/strong><\/th>Field Details<\/strong><\/th>How To Fill It?<\/strong><\/th><\/tr><\/thead>FL 7 <\/td> Reserved<\/td> Leave it blank<\/td><\/tr> FL 8<\/td> Patient name<\/td> Enter the patient’s name exactly as it appears on their insurance card.<\/td><\/tr> FL 9<\/td> Patient address<\/td> Write the full street address, city, state, and ZIP code.<\/td><\/tr> FL 10<\/td> Birthdate<\/td> Enter the patient\u2019s date of birth. Use the 8-digit format MMDDYYYY.<\/td><\/tr> FL 11<\/td> Sex<\/td> Specify the gender of the patient.<\/td><\/tr> FL 12\u201313<\/td> Admission date, hour<\/td> Use the 8-digit MMDDYYYY format for admission date, and 2-digit military time (00\u201323) to specify hours.<\/td><\/tr> FL 14<\/td> Admission type<\/td> Enter a 1-digit code to specify the priority of admission, e.g., 1 for emergency, 2 for urgent, 3 for elective, 4 for newborn, etc.<\/td><\/tr> FL 15<\/td> Source of admission<\/td> Specify whether it is a physician referral, transfer from another facility, etc., using 1 numeric character.<\/td><\/tr> FL 16 <\/td> Discharge hour<\/td> Use 2-digit military time (00\u201323).<\/td><\/tr> FL 17<\/td> Discharge status<\/td> Mention the 2-digit code explaining where the patient went, e.g., 01 (home), 03 (SNF), etc.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\nMedical Events & Values (Fields 18\u201341)<\/strong><\/h3>\n\n\n\nIn this section of the CMS-1450 form, you must report special circumstances, accident details, significant date ranges (occurrence spans), and specific dollar values related to insurance calculations.<\/p>\n\n\n\nField Locator<\/strong><\/th>Field Details<\/strong><\/th>How To Fill It?<\/strong><\/th><\/tr><\/thead>FL 18-28<\/td> Condition codes<\/td> Use 2-digit alphanumeric codes for special circumstances that may affect the processing of this claim.<\/td><\/tr> FL 29<\/td> Accident state<\/td> Mention the 2-digit state abbreviation where the accident occurred.<\/td><\/tr> FL 30<\/td> Reserved<\/td> Leave it blank<\/td><\/tr> FL 31-34<\/td> Occurrence codes, dates<\/td> These fields identify events, like accidents or the symptom onset. Enter the 2-digit code in \u2018a\u2019 and the date in \u2018b\u2019.<\/td><\/tr> FL 35-36<\/td> Occurrence span<\/td> These fields are used for events that happened over a range of time. Enter the 2-digit code in the code box, followed by the ‘from’ and ‘through’ dates.<\/td><\/tr> FL 37<\/td> Reserved <\/td> Leave it blank<\/td><\/tr> FL 38<\/td> Responsible party name and address <\/td> Fill this field if someone other than the patient is financially responsible for the bill. <\/td><\/tr> FL 39-41<\/td> Value codes<\/td> These codes are used for monetary amounts, like Medicare deductibles or semi-private room rates. In the amount box, enter the number, amount, orUCR value associated with that code. Refer to the NUBC manual for specific codes.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n