This chapter provides instructions for filling in the first seven fields on the UB-04 claim form (see Figure 7.1). These fields contain information about the institutional provider of the services that are being billed. Medicare and other payers require this information to process payments correctly and efficiently. For example, the first field contains the provider's name, address, and telephone number, and the second field is used to report the pay-to address if the provider has a separate mailing address for receiving payments. Based on the information in the first two fields, the payer knows where to send a payment.

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The provider information section of the UB-04 also supplies the basic information needed to identify the type of claim being billed. This information includes the type of facility at which the service was received, whether the bill is for inpatient or outpatient services, and whether the bill represents the beginning, middle, or end of an episode of care. Payers must have this information to determine which benefits are currently due, as well as to anticipate benefits due in the future.

Finally, the provider information on the UB-04 includes the from and through dates—the dates of service for the charges being billed. This information is especially important to payers in determining benefits for inpatient care.

Learning Objectives