Table of Contents
Official UB-04 Data Specifications Manual 2021
Table of Contents pages: 1 2 3
- 2021 UB-04 (v. 15.00) 11
- Copyright Notice 22
- Table of Contents 33
- Introduction 55
- Index by Form Locator Number 1111
- FL 01 Billing Provider Name, Address and Telephone Number 1111
- FL 02 Billing Provider's Designated Pay-to Address 1313
- FL 03a Patient Control Number 1414
- FL 03b Medical/Health Record Number 1515
- FL 04 Type of Bill 1616
- FL 04 Type of Bill - Notes p. 1 1616
- FL 04 Type of Bill - Notes p. 2 1717
- FL 04 Type of Bill Codes 000x-064x p. 3 1818
- FL 04 Type of Bill Codes 065x-999x p. 4 1919
- FL 04 Type of Bill Codes p. 5 2020
- FL 04 Type of Bill Frequency Codes 0-6 p. 6 2121
- FL 04 Type of Bill Frequency Codes 7-C p. 7 2222
- FL 04 Type of Bill Frequency Codes D-P p. 8 2323
- FL 04 Type of Bill Frequency Codes Q-Z p. 9 2424
- FL 05 Federal Tax Number 2525
- FL 06 Statement Covers Period (From-Through) 2626
- FL 07 Reserved for Assignment by the NUBC 2929
- FL 08 Patient Name/ Identifier 3030
- FL 09 Patient Address 3131
- FL 10 Patient Birth Date 3232
- FL 11 Patient Sex 3333
- FL 12 Admission/Start of Care Date 3434
- FL 13 Admission Hour 3535
- FL 14 Priority (Type) of Admission or Visit 3636
- FL 15 Point of Origin for Admission or Visit 4040
- FL 15 Point of Origin for Admission or Visit p. 1 4040
- FL 15 Point of Origin for Admission or Visit 1-5 p. 2 4141
- FL 15 Point of Origin for Admission or Visit 6-A p. 3 4242
- FL 15 Point of Origin for Admission or Visit B-Z p. 4 4343
- FL 15 Point of Origin for Admission or Visit Newborn p. 5 4444
- FL 15 Point of Origin for Admission or Visit FAQ p. 6 4545
- FL 15 Point of Origin for Admission or Visit FAQ p. 7 4646
- FL 15 Point of Origin for Admission or Visit FAQ p. 8 4747
- FL 15 Point of Origin for Admission or Visit FAQ p. 9 4848
- FL 16 Discharge Hour 4949
- FL 17 Patient Discharge Status 5050
- FL 17 Patient Discharge Status p. 1 5050
- FL 17 Patient Discharge Status p. 2 5151
- FL 17 Patient Discharge Status 01-05 p. 3 5252
- FL 17 Patient Discharge Status 06-41 p. 4 5353
- FL 17 Patient Discharge Status 42-65 p. 5 5454
- FL 17 Patient Discharge Status 66-91 p. 6 5555
- FL 17 Patient Discharge Status 92-99 p. 7 5656
- FL 17 Patient Discharge Status FAQ p. 8 5757
- FL 17 Patient Discharge Status FAQ p. 9 5858
- FL 17 Patient Discharge Status FAQ p. 10 7474
- FL 17 Patient Discharge Status FAQ p. 11 7575
- FL 17 Patient Discharge Status FAQ p. 12 7676
- FL 17 Patient Discharge Status FAQ p. 13 7777
- FL 17 Patient Discharge Status FAQ p. 14 7878
- FL 17 Patient Discharge Status FAQ p. 15 6464
- FL 18-28 Condition Codes 6565
- FL 18-28 Condition Codes p. 1 6565
- FL 18-28 Condition Codes 01-09 p. 2 6666
- FL 18-28 Condition Codes 10-25 p. 3 6767
- FL 18-28 Condition Codes 26-30 p. 4 6868
- FL 18-28 Condition Codes 31-42 p. 5 6969
- FL 18-28 Condition Codes 43-51 p. 6 7070
- FL 18-28 Condition Codes 52-66 p. 7 7171
- FL 18-28 Condition Codes 67-79 p. 8 7272
- FL 18-28 Condition Codes 80-A2 p. 9 7373
- FL 18-28 Condition Codes A3-AI p. 10 7474
- FL 18-28 Condition Codes AJ-C0 p. 11 7575
- FL 18-28 Condition Codes C1-D6 p. 12 7676
- FL 18-28 Condition Codes D7-H5 p. 13 7777
- FL 18-28 Conditon Codes H6-R4 p.14 7878
- FL 18-28 Conditon Codes R5-VZ p. 15 7979
- FL 18-28 Conditon Codes W0-ZZ p. 16 8080
- FL 29 Accident State 8181
- FL 30 Reserved for Assignment by the NUBC 8282
- FL 31-34/35-36 Occurrence and Occurrence Span Codes and Dates - Guidelines p, 1 8383
- FL 31-34 Occurrence Codes and Dates p. 2 8484
- FL 31-34 Occurrence Codes and Dates 01-16 p. 3 8585
- FL 31-34 Occurrence Codes and Dates 17-28 p. 4 8686
- FL 31-34 Occurrence Codes and Dates 29-39 p. 5 8787
- FL 31-34 Occurrence Codes and Dates 40-50 p. 6 8888
- FL 31-34 Occurrence Codes and Dates 51-A0 p. 7 8989
- FL 31-34 Occurrence Codes and Dates A1-E3 p. 8 9090
- FL 31-34 Occurrence Codes and Dates E4-ZZ p. 9 9191
- FL 35-36 Occueence Span Codes and Dates 9292
- FL 37 Reserved for Assignment by the NUBC 9696
- FL 38 Responsible Party Name and Address (Claim Addressee) 9797
- FL 39-41 Value Codes and Amounts 9898
- FL 39-41 Value Codes and Amounts p. 1 9898
- FL 39-41 Value Codes and Amounts p. 2 9999
- FL 39-41 Value Codes and Amounts p. 3 100100
- FL 39-41 Value Codes and Amounts 01-08 p. 4 101101
- FL 39-41 Value Codes and Amounts 09-15 p. 5 102102
- FL 39-41 Value Codes and Amounts 16-30 p. 6 103103
- FL 39-41 Value Codes and Amounts 31-40 p. 7 104104
- FL 39-41 Value Codes and Amounts 41-43 p. 8 105105
- FL 39-41 Value Codes and Amounts 44-45 p. 9 106106
- FL 39-41 Value Codes and Amounts 46-49 p. 10 107107
- FL 39-41 Value Codes and Amounts 50-55 p. 11 108108
- FL 39-41 Value Codes and Amounts 56-65 p. 12 109109
- FL 39-41 Value Codes and Amounts 66-85 p. 13 110110
- FL 39-41 Value Codes and Amounts 86-A4 p. 14 111111
- FL 39-41 Value Codes and Amounts A5-A9 p. 15 112112
- FL 39-41 Value Codes and Amounts AA-B9 p. 16 113113
- FL 39-41 Value Codes and Amounts BA-D2 p. 17 114114
- FL 39-41 Value Codes and Amounts D3-EZ p. 18 115115
- FL 39-41 Value Codes and Amounts F0-OZ p. 19 116116
- FL 39-41 Value Codes and Amounts P0-ZZ p. 20 117117
- FL 42 Revenue Codes 118118
- FL 42 Revenue Codes p. 1 118118
- FL 42 Revenue Codes p. 2 119119
- FL 42 Revenue Codes 0000-009x p. 3 120120
- FL 42 Revenue Codes 010x-011x p. 4 121121
- FL 42 Revenue Codes 012x-013x p. 5 122122
- FL 42 Revenue Codes 014x-015x p. 6 123123
- FL 42 Revenue Codes 016x p. 7 124124
- FL 42 Revenue Codes 017x p. 8-9 125125
- FL 42 Revenue Codes 018x-019x p. 10 127127
- FL 42 Revenue Codes 020x-021x p. 11 128128
- FL 42 Revenue Codes 022x-023x p. 12 129129
- FL 42 Revenue Codes 024x-025x p. 13 130130
- FL 42 Revenue Codes 026x p. 14 131131
- FL 42 Revenue Code 027x p. 15 132132
- FL 42 Revenue Codes 028x-030x p. 16 133133
- FL 42 Revenue Codes 031x p. 17 134134
- FL 42 Revenue Codes 032x-033x p. 18 135135
- FL 42 Revenue Codes 034x-035x p. 19 136136
- FL 42 Revenue Codes 036x-037x p. 20 137137
- FL 42 Revenue Codes 038x-039x p. 21 138138
- FL 42 Revenue Codes 040x p. 22 139139
- FL 42 Revenue Codes 041x-042x p. 23 140140
- FL 42 Revenue Codes 043x-044x p. 24 141141
- FL 42 Revenue Codes 045x p. 25 142142
- FL 42 Revenue Codes 046x p. 26 143143
- FL 42 Revenue Codes 047x-048x p. 27 144144
- FL 42 Revenue Codes 049x-051x p. 28 145145
- FL 42 Revenue Codes 052x p. 29 146146
- FL 42 Revenue Codes 053x p. 30 147147
- FL 42 Revenue Codes 054x-055x p. 31 148148
- FL 42 Revenue Codes 056x-057x p. 32 149149
- FL 42 Revenue Codes 058x-059x p. 33 150150
- FL 42 Revenue Codes 060x-061x p. 34 151151
- FL 42 Revenue Codes 062x p. 35 152152
- FL 42 Revenue Codes 063x p. 36 153153
- FL 42 Revenue Codes 064x p. 37 154154
- FL 42 Revenue Codes 065x p. 38 155155
- FL 42 Revenue Codes 066x-067x p. 39 156156
- FL 42 Revenue Codes 068 x p. 40 157157
- FL 42 Revenue Codes 069x-071x p. 41 158158
- FL 42 Revenue Codes 072x-073x p. 42 159159
- FL 42 Revenue Codes 074x-075x p. 43 160160
- FL 42 Revenue Codes 076x-077x p. 44 161161
- FL 42 Revenue Codes 078x-079x p. 45 162162
- FL 42 Revenue Codes 080x p. 46 163163
- FL 42 Revenue Codes 081x p. 47 164164
- FL 42 Revenue Codes 082x-083x p. 48 165165
- FL 42 Revenue Codes 084x-085x p. 49 166166
- FL 42 Revenue Codes 086x-087x p. 50 167167
- FL 42 Revenue Codes 088x-089x p. 51 168168
- FL 42 Revenue Codes 090x-091x p. 52 169169
- FL 42 Revenue Codes 092x-093x p. 53 170170
- FL 42 Revenue Codes 094x-095x p. 54 171171
- FL 42 Revenue Codes 096x-097x p. 55 172172
- FL 42 Revenue Codes 098x-099x p. 56 173173
- FL 42 Revenue Codes 100x-209x p. 57 174174
- FL 42 Revenue Codes 210x-309x p. 58 175175
- FL 42 Revenue Codes 310x p. 59 176176
- FL 42 Revenue Codes 311x-9999 p. 60 177177
- FL 43 Revenue Description/IDE Number/Medicaid Drug Rebate/Line Level Rendering Provider NPI 178178
- FL 45 Service/Assessment Date 182182
- FL 46 Service Units 183183
- FL 47 Total Charges 184184
- FL 48 Non-covered Charges 185185
- FL 49 Reserved for Assignment by the NUBC 186186
- FL 50 Payer Name 187187
- FL 51 Payer ID 188188
- FL 52 Release of Information Certification Indicator 189189
- FL 53 Assignment of Benefits Certification Indicator 190190
- FL 54 Prior Payments - Payer 191191
- FL 55 Estimated Amount Due - Payer 192192
- FL 56 National Provider Identifier - Billing Provider 193193
- FL 57 Other (Billing) Provider Identifier 194194
- FL 58 Insured's Name 195195
- FL 59 Patient's Relationship to Insured 196196
- FL 60 Insured's Unique Identifier 197197