Guide to the UB-04 Form: How to Fill Out, Instructions

The UB-04 form is a standardized medical billing form used by institutional providers for both inpatient and outpatient claims. It plays a crucial role in the healthcare industry, allowing providers to bill insurance companies and government programs accurately. In this comprehensive guide, we will explore various aspects of the UB-04 form, including how to fill it out, field descriptions, instructions, and frequently asked questions. By understanding the intricacies of this form, healthcare professionals can ensure accurate billing and avoid potential reimbursement issues.

I. Understanding the UB-04 Form:

The UB-04 form, also known as the CMS-1450 form, is used by institutional providers to bill Medicare fiscal intermediaries, Medicaid State Agencies, and insurance companies for institutional charges [1]. Developed by the National Uniform Billing Committee (NUBC), this standardized form consists of 81 fields, each serving a specific purpose [1]. Let's dive deeper into some of the key components of the UB-04 form:

1. Provider Information:

   - Field 1: Billing Provider Name, Address, and Telephone Number

   - Field 2: Pay-to Provider Name, Address, and Telephone Number

   - Field 3: Facility Name

   - Field 4: Type of Bill


2. Patient Details:

   - Field 6: Patient Name

   - Field 8: Patient Birth Date

   - Field 11: Insured's Policy Group, or FECA Number


3. Dates of Service:

   - Field 45: Service Date

   - Field 46: Service Units


4. Type of Visit:

   - Field 51: Health Plan ID

   - Field 54: Prior Payments


5. Occurrence Codes:

   - Field 31: Occurrence Code and Date

   - Field 35: Occurrence Span Code and Dates


6. Revenue Codes:

   - Field 42: Revenue Code

   - Field 43: Revenue Description


7. Insurance-Related Fields:

   - Field 50: Payer Name 

It is essential to carefully enter data in each designated field and adhere to the specific requirements of insurance payers to ensure accurate billing and reimbursement [[1](].

II. How to Fill Out the UB-04 Form:

How to complete a CMS 1500 claim form in 5 minutes!

To fill out the UB-04 form correctly, healthcare providers should follow these step-by-step instructions:

1. Gather the necessary information:

   - Patient demographics (name, date of birth, gender)

   - Insurance details (payer name, policy group/FECA number)

   - Dates of service and service units

   - Revenue codes and descriptions


2. Complete the provider information:

   - Enter the billing provider's name, address, and telephone number (Field 1)

   - Provide the pay-to provider's name, address, and telephone number (Field 2)

   - Specify the facility name (Field 3)

   - Select the appropriate type of bill code (Field 4)

3. Fill in the patient details:

   - Enter the patient's name (Field 6)

   - Provide the patient's birth date (Field 8)

  - Include the insured's policy group or FECA number (Field 11)

4. Record the dates of service:

   - Enter the service date (Field 45)

   - Specify the service units (Field 46)

5. Indicate the type of visit and prior payments:

   - Include the health plan ID (Field 51)

   - Provide information about prior payments (Field 54)

6. Include occurrence codes and dates:

   - Enter any relevant occurrence codes and dates (Field 31)

   - Specify occurrence span codes and dates if applicable (Field 35)

7. Enter revenue codes and descriptions:

   - Provide the appropriate revenue code for each service (Field 42)

   - Include a brief description of the revenue (Field 43)

8. Include insurance-related information:

   - Specify the payer name (Field 50)

By following these instructions and understanding the purpose of each field, healthcare providers can accurately complete the UB-04 form and facilitate seamless billing [1].

III. UB-04 Form Field Descriptions:

To better understand the purpose of each field in the UB-04 form, here are some essential field descriptions:

1. Field 1: Billing Provider Name, Address, and Telephone Number:

   This field captures the details of the provider who is billing for the services rendered.

2. Field 6: Patient Name:

   The patient's full name should be entered in this field.

3. Field 31: Occurrence Code and Date:

   Occurrence codes are used to report significant events related to the claim, such as the start of hospice care or the occurrence of an accident.

4. Field 42: Revenue Code:

   Revenue codes indicate the specific services provided and help determine the reimbursement amount.

5. Field 50: Payer Name:

   This field captures the name of the insurance company or payer responsible for the claim.

By understanding these field descriptions, healthcare professionals can accurately complete the UB-04 form and ensure precise billing [1]

IV. FAQs about the UB-04 Form:

1. What is the difference between a UB-04 form and a CMS-1500 form?

   The UB-04 form is used by institutional providers for inpatient and outpatient claims, while the CMS-1500 form is used by non-institutional providers [[1](].

2. How can I obtain a blank UB-04 form?

   Providers can obtain blank copies of the UB-04 form from office supply stores or download them from reputable sources like the NUBC website [[2](].


The UB-04 form is a vital tool for institutional providers to accurately bill insurance companies and government programs for their services. By understanding how to fill out the form correctly, healthcare professionals can avoid billing errors and ensure prompt reimbursement. With its standardized format and comprehensive field descriptions, the UB-04 form streamlines the billing process and facilitates efficient communication between providers and payers. By following the instructions provided in this guide, healthcare professionals can confidently complete the UB-04 form and navigate the complex landscape of medical billing.


1. How the UB-04 Form Is Used to Bill Insurance Companies - Verywell Health

2. Institutional paper claim form (CMS-1450) |CMS