Table of Contents
Official UB-04 Data Specifications Manual 2021
Table of Contents pages: 1 2 3
- Revenue Codes 086x-087x p. 50 FL 42 167167
- Revenue Codes 088x-089x p. 51 FL 42 168168
- Revenue Codes 090x-091x p. 52 FL 42 169169
- Revenue Codes 092x-093x p. 53 FL 42 170170
- Revenue Codes 094x-095x p. 54 FL 42 171171
- Revenue Codes 096x-097x p. 55 FL 42 172172
- Revenue Codes 098x-099x p. 56 FL 42 173173
- Revenue Codes 100x-209x p. 57 FL 42 174174
- Revenue Codes 210x-309x p. 58 FL 42 175175
- Revenue Codes 310x p. 59 FL 42 176176
- Revenue Codes 311x-9999 p. 60 FL 42 177177
- Revenue Description /IDE Number/Medicaid Drug Rebate/Line Level Rendering Provider NPI FL 43 178178
- Service/Assessment Date FL 45 182182
- Service Units FL 46 183183
- Statement Covers Period (From-Through) FL 06 2626
- Total Charges FL 47 184184
- Type of Bill FL 04 1616
- Type of Bill Codes - Notes p. 1 FL 04 1616
- Type of Bill Codes - Notes p. 2 FL 04 1717
- Type of Bill Codes 000x-064x p. 3 FL 04 1818
- Type of Bill Codes 065x-999x p. 4 FL 04 1919
- Type of Bill Codes p. 5 FL 04 2020
- Type of Bill Frequency Codes 0-6 p. 6 FL 04 2121
- Type of Bill Frequency Codes 7-C p. 7 FL 04 2222
- Type of Bill Frequency Codes D-P p. 8 FL 04 2323
- Type of Bill Frequency Codes Q-Z p. 9 FL 04 2424
- Value Codes and Amounts FL 39-41 9898
- Value Codes and Amounts p. 1 FL 39-41 9898
- Value Codes and Amounts p. 2 FL 39-41 9999
- Value Codes and Amounts p. 3 FL 39-41 100100
- Value Codes and Amounts 01-08 p. 4 FL 39-41 101101
- Value Codes and Amounts 09-15 p. 5 FL 39-41 102102
- Value Codes and Amounts 16-30 p. 6 FL 39-41 103103
- Value Codes and Amounts 31-40 p. 7 FL 39-41 104104
- Value Codes and Amounts 41-43 p. 8 FL 39-41 105105
- Value Codes and Amounts 44-45 p. 9 FL 39-41 106106
- Value Codes and Amounts 46-49 p. 10 FL 39-41 107107
- Value Codes and Amounts 50-55 p. 11 FL 39-41 108108
- Value Codes and Amounts 56-65 p. 12 FL 39-41 109109
- Value Codes and Amounts 66-85 p. 13 FL 39-41 110110
- Value Codes and Amounts 86-A4 p. 14 FL 39-41 111111
- Value Codes and Amounts A5-A9 p. 15 FL 39-41 112112
- Value Codes and Amounts AA-B9 p. 16 FL 39-41 113113
- Value Codes and Amounts BA-D2 p.17 FL 39-41 114114
- Value Codes and Amounts D3-EZ p.18 FL 39-41 115115
- Value Codes and Amounts F0-OZ p. 19 FL 39-41 116116
- Value Codes and Amounts P0-ZZ p. 20 FL 39-41 117117
- State Guidelines 229229
- Appendix 269269
- Minutes 1010