2020 Table of Contents Page 1 of 2 Introduction 5 Form Locators FL 01 - Billing Provider Name, Address and Telephone Number 11 FL 02 - Billing Provider’s Designated Pay-to Address 13 FL 03a - Patient Control Number 14 FL 03b - Medical/Health Record Number 15 FL 04 - Type of Bill 16 FL 05 - Federal Tax Number 25 FL 06 - Statement Covers Period (From - Through) 26 FL 07 - Reserved for Assignment by the NUBC 29 FL 08 - Patient Name/Identifier 30 FL 09 - Patient Address 31 FL 10 - Patient Birth Date 32 FL 11 - Patient Sex 33 FL 12 - Admission/Start of Care Date 34 FL 13 - Admission Hour 35 FL 14 - Priority (Type) of Admission or Visit 36 FL 15 - Point of Origin for Admission or Visit 40 FL 16 - Discharge Hour 49 FL 17 - Patient Discharge Status 50 FL 18-28 - Condition Codes 65 FL 29 - Accident State 81 FL 30 - Reserved for Assignment by the NUBC 82 FL 31-34 - Occurrence Codes and Dates 83 FL 35-36 - Occurrence Span Codes and Dates 92 FL 37 - Reserved for Assignment by the NUBC 96 FL 38 - Responsible Party Name and Address (Claim Addressee) 97 FL 39-41 - Value Codes and Amounts 98 FL 42 - Revenue Codes 117 FL 43 - Revenue Description/IDE Number/Medicaid Drug Rebate/ Line Level 176 Rendering Provider NPI FL 44 - HCPCS/Accommodation Rates/HIPPS Rate Codes 178 FL 45 - Service/Assessment Date 180 FL 46 - Service Units 181 FL 47 - Total Charges 182 FL 48 - Non-covered Charges 183 FL 49 - Reserved for Assignment by the NUBC 184 FL 50 - Payer Name 185 FL 51 - Payer ID/Health Plan ID 186 FL 52 - Release of Information Certification Indicator 187 FL 53 - Assignment of Benefits Certification Indicator 188 FL 54 - Prior Payments - Payer 189 FL 55 - Estimated Amount Due - Payer 190 FL 56 - National Provider Identifier - Billing Provider 191 FL 57 - Other (Billing) Provider Identifier 192 FL 58 - Insured’s Name 193 FL 59 - Patient’s Relationship to Insured 194 FL 60 - Insured’s Unique Identifier 195 National Uniform Billing Committee Official UB-04 Data Specifications Manual 2020 AHA © 2019 Single User License (Expires 6/30/2020) Please do not copy or distribute Version 14.00 July 2019 Page 3 of 292
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