FLs 1-7 on the UB-04 contain information about the provider of the services being billed. This includes provider identifying information, the patient account number and medical/health record number assigned by the provider, information identifying the type of claim being billed, a federal tax number, and the dates of service covered by the claim.
2. Each field on the UB-04 requires the use of a particular format for entering data. Important formatting requirements in the Provider section (FLs 1-7) include these: punctuation is acceptable, and up to four lines of text are allowed in FL 1 (Provider Name, Address, and Telephone Number); no spaces should be used between digits in FL
3a (Patient Control Number); FL 4 (TOB) must always contain a leading zero followed by three other digits; and the dates in FL 6 (Statement Covers Period) should be reported in the MMDDYY format. The formatting rules for some of these form locators are different on the corresponding electronic HIPAA claim.
The type of bill (TOB) code in FL 4 is a four-digit code comprised of a leading zero followed by three digits that relay three specific pieces of information about the services being billed. The second digit identifies the type of facility in which the services were received, for example, a clinic. The third digit classifies the type of care being billed, such as intermediate care. The last digit indicates the sequence of the bill within a given episode of care, for example, an admit through discharge claim. The TOB can be thought of as having two components: the second and third digits combined make up the bill type component, and the last digit makes up the frequency code.
Many fields on the UB-04 contain data that need to be coordinated with data in other fields. For example, certain TOB codes in FL 4 necessitate data entry in the Revenue Code field (FL 42) and/or in the Condition Codes fields (FLs 18-28).
An important field on the UB-04 is the Statement Covers Period field (FL 6). The dates of service reported here are key in determining a patient's benefits. For inpatient bills, the total number of days represented in this field must be equal to the sum of covered days and non-covered days recorded in FLs 39-41 (Value Codes and Amounts) on the UB-04 using value codes 80 and 81.
