UB-04 Form in Medical Billing - A Complete Guide for Institutional Claims

In facility-based healthcare billing, the UB-04 form stands as one of the most important documents in the revenue cycle. It's the standardized form used by hospitals, nursing facilities, rehab centers, and similar institutions to report claims to insurance carriers. 

Yet, despite how frequently it’s used, many professionals only scratch the surface of how this form actually functions—and how much hinges on getting it right. Often referred to as the CMS-1450, the UB-04 isn’t just another billing document—it’s a highly structured, detail-driven tool that communicates the full spectrum of services delivered in a facility setting. 

From inpatient hospital stays to outpatient surgeries and hospice care, this form consolidates vast amounts of clinical and financial data into a format that payers—both government and commercial—can process and adjudicate.

This guide takes a closer look at the UB-04 from every angle—what it is, when to use it, how it's structured, and what details truly matter. Whether you're new to institutional billing or looking to sharpen your understanding of claim mechanics, this walkthrough will help you to understand the form with clarity and confidence.

What Is the UB-04 Claim Form?

The UB-04 claim form, also known as CMS-1450, is the official billing form used by institutional providers to submit claims for reimbursement to Medicare, Medicaid, and most private insurance companies.

Originally introduced by the National Uniform Billing Committee (NUBC), the UB-04 replaced the older UB-92 form in 2007. Since then, it has become the universal billing format for institutions that provide care on a facility level, as opposed to individual practitioners, who typically use the CMS-1500 form.

Where the CMS-1500 focuses on professional services—think office visits, consultations, or diagnostic testing done by a physician or outpatient provider—the UB-04 captures the broader, more complex nature of institutional care. This includes room and board charges, operating room fees, ancillary services, and revenue codes tied to each line item.

The form itself contains 81 numbered fields (referred to as "Form Locators") that gather data ranging from patient demographics and insurance information to service codes, diagnosis details, and billing specifics. Each field must be filled out accurately to ensure the claim is processed smoothly, and many payers require specific formatting or additional documentation depending on the type of service or facility.

Field-by-Field Breakdown for Inpatient vs. Outpatient Billing in UB-04 Form

The UB-04 claim form includes 81 fields, known as Form Locators (FLs). While the form itself doesn't change between inpatient and outpatient claims, the type of data entered into specific fields often does—based on the level of care, length of stay, type of service, and payer requirements.

Below is a breakdown of key Form Locators, focusing on how each is typically used in inpatient vs. outpatient billing scenarios

Field Location	Description	Inpatient	Outpatient
1	Provider Name and Address	Required	Required
2	Pay-To Name and Address	Situational	Situational
3a	Patient Control Number	Required	Required
3b	Medical Record Number	Situational	Situational
4	Type of Bill	Required	Required
5	Federal Tax Number	Required	Required
6	Statement Covers Period	Required	Required
7	Future Use	N/A	N/A
8a	Patient ID	Situational	Situational
8b	Patient Name	Required	Required
9	Patient Address	Required	Required
10	Patient Birthdate	Required	Required
11	Patient Sex	Required	Required
12	Admission Date	Required	Required, if applicable
13	Admission Hour	Required	Required, if applicable
14	Type of Admission/Visit	Required	Required
15	Source of Admission	Required	Required
16	Discharge Hour	Required	N/A
17	Patient Discharge Status	Required	Required
18-28	Condition Codes	Required, if applicable	Required, if applicable
29	Accident State	Situational	Situational
30	Future Use	N/A	N/A
31-34	Occurrence Codes and Dates	Required, if applicable	Required, if applicable
35-36	Occurrence Span Codes and Dates	Required, if applicable	Required, if applicable
37	Future Use	N/A	N/A
38	Responsible Party Name and Address	Required, if applicable	Required, if applicable
39-41	Value Codes and Amounts	Required, if applicable	Required, if applicable
42	Revenue Code	Required	Required
43	Revenue Code Description / NDC	Required, if applicable	Required, if applicable
44	HCPCS/Rates	Required, if applicable	Required, if applicable
45	Service Date	N/A	Required
46	Units of Service	Required	Required
47	Total Charges (By Rev. Code)	Required	Required
48	Non-Covered Charges	Required, if applicable	Required, if applicable
49	Future Use	N/A	N/A
50	Payer Identification (Name)	Required	Required
51	Health Plan Identification Number	Situational	Situational
52	Release of Info Certification	Required	Required
53	Assignment of Benefit Certification	Required	Required
54	Prior Payments	Required, if applicable	Required, if applicable
55	Estimated Amount Due	Required	Required
56	NPI	Required	Required
57	Other Provider IDs	Optional	Optional
58	Insured’s Name	Required	Required
59	Patient’s Relation to the Insured	Required	Required
60	Insured’s Unique ID	Required	Required
61	Insured Group Name	Situational	Situational
62	Insured Group Number	Situational	Situational
63	Treatment Authorization Codes	Required, if applicable	Required, if applicable
64	Document Control Number	Situational	Situational
65	Employer Name	Situational	Situational
66	Diagnosis/Procedure Code Qualifier	Required, if applicable	Required, if applicable
67	Principal Diagnosis Code	Required	Required
67A-Q	Other Diagnoses Codes	Situational	Situational
68	Future Use	N/A	N/A
69	Admitting Diagnosis Code	Required	Situational
70	Patient’s Reason for Visit Code	Situational	Situational
71	PPS Code	Situational	Situational
72	External Cause of Injury Code	Situational	Situational
73	Future Use	N/A	N/A
74	Principal Procedure Code/Date	Required, if applicable	Required, if applicable
74A-E	Other Procedure Codes/Date	Situational	Situational
75	Attending Name/ID/Qualifier 1G	Required	Required
76-77	Operating ID	Situational	Situational
78-79	Other Provider ID	Situational	Situational
80	Remarks	Situational	Situational
81	Code-Code Field/Qualifiers	N/A	N/A

 

How to Get a UB-04 Form from a Hospital

The UB-04 (CMS-1450) form is a standardized claim form used by hospitals and institutional providers to bill insurance companies for services. While it's primarily used in payer communications, patients may need a copy for secondary insurance claims, appeals, tax purposes, or legal verification.

Here’s how you can get your copy—whether directly from the hospital or through other channels:

✅ 1. Contact the Hospital’s Billing or Medical Records Department

Start by calling the hospital’s Billing Department, Patient Accounts, or Health Information Management (HIM).

What to say:
Ask for a copy of the UB-04 claim form submitted for your specific date(s) of service.

Be prepared to provide:

• Patient’s full name

• Date of birt

• Date of service or hospitalization

• Medical record or account number (if available

📝 Be specific—clarify that you're not requesting an itemized bill or explanation of benefits (EOB). You're asking for the UB-04 institutional claim form submitted to insurance.

✅ 2. Check Online Patient Portals

Many hospitals now offer secure online patient portals (like MyChart or Cerner) that may allow access to billing documents.

Look for sections labeled:

• Billing Statements

• Insurance Claims

• Request Records or Documents

If it’s not downloadable directly, use the portal’s secure messaging tool to request the UB-04 from billing support.
Download ub-04 form Here!

💡 Pro tip: If the form isn't available in the portal, ask if they can email or fax it securely after verifying your identity.

✅ 3. Request Through Your Insurance Company

If the hospital has already submitted the UB-04 to your insurer, you may be able to get a copy directly from your insurance company.

Steps:

• Call your insurance’s Member Services

• Request the UB-04 claim form for a specific date of service

• Ask for it to be sent via secure email, portal download, or mail

Some payers (including Medicare and Medicaid) may require you to submit a release form, especially if you're requesting on behalf of someone else.

📌 Why this works: Insurance carriers often store copies of institutional claims, including all UB-04 fields and charge codes, especially for inpatient or emergency claims.

✅ 4. Submit a Written Request (if required)

Some facilities require a signed, written request to release the UB-04 form. You may need to fill out a HIPAA release form.

Include:

• Patient’s full name and date of birth

• Dates of service

• Type of document requested (UB-04 form)

• Signature of patient or legal representative

• Any required ID or legal documentation (e.g., POA)

Send it to the billing office or HIM department via mail, email, or fax as instructed.

⏳ 5. Know the Processing Timeline

• Most requests are processed within 5–10 business days

• Some facilities may charge a nominal fee (though UB-04s are often provided free)

• If you're in a hurry, always ask if fax or encrypted email delivery is available

Who Can Request It?

Only the following individuals can typically access a UB-04 form:

• The patient

• A legal guardian

• A power of attorney (POA)

• An authorized representative with a valid HIPAA release

What Is the UB-04 Form Used For?

The UB-04 form is used exclusively by institutional healthcare providers to bill payers for facility-based services. It’s not a general-purpose billing form—it’s tailored for high-volume, structured claims involving hospital stays, outpatient procedures performed at a facility, and other complex care scenarios.

1. Hospital Inpatient Claims

When a patient is admitted to a hospital, the UB-04 is used to bill:

• Room and board (daily charges)

• Nursing services

• Operating room and anesthesia fees

• Lab tests and imaging performed during admission

• Pharmacy and supply charges

• Post-surgical recovery care

➡ Used by: Acute care hospitals, LTACs, psychiatric hospitals

2. Hospital Outpatient Claims

Facilities use the UB-04 for outpatient services performed at the hospital, such as:

• Same-day surgeries

• Emergency department visits

• Observation stays

• Outpatient labs, X-rays, and MRIs

• Outpatient infusion therapy or chemotherapy

➡ Used by: Hospital outpatient departments, ambulatory surgery centers (ASCs)

3. Skilled Nursing Facility (SNF) Claims

When billing Medicare or Medicaid for skilled care (e.g., IV therapy, wound care, rehab) after a hospital discharge, SNFs must use the UB-04.

➡ Includes:

• Daily RUG-based payment details

• MDS-related occurrence codes

• Revenue lines by service (therapy, nursing, labs)

4. Home Health & Hospice Billing

UB-04 is used to bill for home-based services under Part A (for Medicare) and many Medicaid programs.

➡ Examples:

• Skilled nursing visits

• Physical/occupational therapy at home

• Hospice care (per diem billing)

➡ Used by: Certified Home Health Agencies, Hospice providers

5. Rehabilitation and Behavioral Health Facilities

Facilities offering intensive outpatient or residential rehab programs (physical, occupational, or mental health-related) use UB-04 to bill structured services.

➡ Examples:

• Substance abuse inpatient programs

• Mental health partial hospitalization

• Physical rehab after injury or stroke

6. Medicare and Medicaid Institutional Claims

The UB-04 is the only accepted institutional billing format for Medicare Part A and many state Medicaid programs.

➡ Required for:

• Medicare Advantage facility claims

• Medicaid institutional billing (hospital, SNF, hospice)

7. Payer-Specific Claims with Revenue Codes

Some commercial insurance plans require institutional claims to be submitted on a UB-04 only if the service includes revenue codes, such as:

• Observation stays

• Emergency visits at a facility

• Facility fee components of surgeries

Difference Between UB-04 and CMS-1500 Forms

While both the UB-04 (CMS-1450) and CMS-1500 are standard claim forms used in healthcare billing, they are designed for very different types of providers and services. Understanding when and how each form is used is essential for clean claims, proper reimbursement, and regulatory compliance.

 UB-04 Form (CMS-1450)

Purpose	Used by institutional providers to bill for facility-based services
Used By	Hospitals, SNFs, Rehab centers, Hospice agencies, Home Health providers
Claim Type	Institutional claims under Medicare Part A, Medicaid, and commercial payers
Structure	Contains up to 81 fields (form locators), includes revenue codes, room & board charges, occurrence codes, and diagnosis/procedure codes
Format	Red-ink paper or electronic (837I format for EDI submission)

CMS-1500 Form (HCFA 1500)

Purpose	Used by individual healthcare providers to bill for professional services
Used By	Physicians, nurse practitioners, therapists, diagnostic centers, DME suppliers
Claim Type	Professional claims under Medicare Part B, Medicaid, and private payers
Structure	Contains 33 numbered fields, focused on provider, diagnosis, CPT/HCPCS codes, and NPI
Format	Red-ink paper or electronic (837P format for EDI submission)

 

Pro Tip for Billers:

If the service was rendered at a facility, and includes room charges, anesthesia, surgical suite fees, or per diem billing—it almost always belongs on a UB-04.

If it’s a face-to-face service by a physician or clinician, with CPT/HCPCS codes and no facility fee—then it’s a CMS-1500.