What is the UB-04 used for?

The UB-04 documents institutional facility charges, patient details, diagnosis and procedure codes, and payer data for Medicare, Medicaid, and commercial payers; it supports claims adjudication and audit trails.

How do I correct a submitted claim?

Follow the payer's corrected claim process—usually submit a replacement claim with corrected fields and a remark code or use the payer's electronic adjustment workflow; retain documentation of the correction and original submission.

Can the UB-04 be electronically signed?

Yes; electronic signatures are legally valid under ESIGN and UETA when intent, consent, attribution, and retention are satisfied. For PHI, ensure a HIPAA BAA with the eSignature provider.

Which attachments are required?

Attach supporting clinical documentation, prior authorizations, and itemized bills per payer instructions; requirements vary by payer and service type, so consult payer-specific guidances.

Who can sign the UB-04?

An authorized billing representative or delegated signatory listed on provider enrollment records should sign or certify; signatures must align with enrollment to avoid audit disputes.

How long until payment?

Adjudication time varies by payer and claim completeness; complete claims often adjudicate within 30–60 days, but unresolved edits or audits can extend timelines significantly.

UB-04 Claim Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

New UB-04 Form & Instructions

This form provides instructions and sample fields for the UB-04 claim form used for institutional billing. Fields shown below reflect the visual structure and sample entries from the document pages.

UB-04 Data Field Requirements

Field Location	Description	Inpatient	Outpatient	Input
1	Provider Name and Address	Required	Required
2	Pay-To Name and Address	Situational	Situational
3a	Patient Control Number	Required	Required
3b	Medical Record Number	Required	Required
4	Type of Bill	Required	Required
5	Federal Tax Number	Required	Required
6	Statement Covers Period	Required	Required	From Through
8a	Patient ID	Situational	Situational
8b	Patient Name	Required	Required
9	Patient Address	Required	Required
10	Patient Birthdate	Required	Required
11	Patient Sex	Required	Required
12	Admission Date	Required	Required
13	Admission Hour	Required	Required
14	Type of Admission/Visit	Required	N/A
15	Source of Admission	Required	Required
16	Discharge Hour	Required	Required
17	Patient Discharge Status	Required	Required
18-28	Condition Codes	Required if Applicable	Required if Applicable
29	Accident State	Situational	Situational
31-34	Occurrence Code and Dates	Required if Applicable	Required if Applicable
35-36	Occurrence Span Codes and Dates	Required if Applicable	Required if Applicable
38	Subscriber Name and Address	Required	Required
39-41	Value Codes and Amounts	Required if Applicable	Required if Applicable
42	Revenue Code	Required	Required
43	Revenue Code Description	Required	Required
44	HCPCS/Rates	Required if Applicable	Required if Applicable
45	Service Date	N/A	Required
46	Units of Service	Required	Required
47	Total Charges (By Rev. Code)	Required	Required
48	Non-Covered Charges	Required if Applicable	Required if Applicable
50	Payer Identification (Name)	Required	Required
51	NPI	Required	Required
52	Release of Info Certification	Required	Required	Certification approved
53	Assignment of Benefit Certification	Required	Required	Certification approved
54	Prior Payments	Required if Applicable	Required if Applicable
55	Estimated Amount Due	Required	Required
56	NPI	Required	Required
57	Health Plan IDs	Required	Required
58	Insured’s Name	Required	Required
59	Patient’s Relation to the Insured	Required	Required
60	Insured’s Unique ID	Required	Required
63	Treatment Authorization Codes	Required if Applicable	Required if Applicable
66	Diagnosis/Procedure Code Qualifier	Required	Required
67	Principal Diagnosis Code/Other Diagnosis Codes	Required	Required
69	Admitting Diagnosis Code	Required	Required if Applicable
70	Patient’s Reason for Visit Code	Situational	Situational
71	PPS Code	Situational	Situational
72	External Cause of Injury Code	Situational	Situational
74	Principal Procedure Code/Date	Required if Applicable	Required if Applicable
76	Attending Name/ ID-Qualifier	Required	Required
77	Operating ID	Situational	Situational
78-79	Other ID	Situational	Situational
80	Remarks	Situational	Situational

837 I Data Field Requirements

The document also includes electronic transaction loop references for billing provider, pay-to provider, attending physician, and service facility location (page 3). These are informational and not typically completed as form inputs.

Sample Claim Entry Section

The sample inpatient and outpatient pages show a dense UB-04 layout with fields such as patient name, patient address, statement period, revenue codes, service dates, total charges, payer name, insured name, diagnosis, procedure codes, and remarks. The following section provides a simplified, semantic input area matching that structure.

Patient Name

Patient ID

Birthdate

Patient Address

Subscriber Name and Address

Statement From

Statement Through

Type of Bill

Revenue Code

Service Date

Units of Service

Total Charges

Payer Name

Insured’s Unique ID

NPI

Diagnosis Code

Procedure Code

Procedure Date

Attending Physician Signature

Date

Authorized Representative Signature

Date

What the UB-04 Claim Form Is and where it fits

The UB-04 Claim Form, also known as the CMS-1450, is the standard administrative claim form used by institutional providers in the United States to bill Medicare, Medicaid, and third-party payers for facility services. It captures patient demographics, admission and discharge details, revenue center service lines, diagnosis and procedure codes, and payer information required for institutional claims processing. The form is issued by the National Uniform Billing Committee and maintained for use across hospitals, skilled nursing facilities, inpatient rehabilitation, and other institutional providers to ensure uniform, auditable billing and remittance.

Why completing the UB-04 accurately matters

Using a properly completed UB-04 reduces claim denials, speeds reimbursement, and creates an auditable record of facility services for insurers and regulators. Standardization supports downstream coding, compliance reviews, and correct allocation of charges across revenue centers.

Who prepares and relies on the UB-04

Institutional billing teams, health information management coders, and revenue cycle staff prepare the UB-04 before submitting facility claims.

Hospital billing departments managing inpatient and outpatient facility services and chargemaster reconciliation.
Skilled nursing and long-term care providers submitting Medicare and Medicaid facility claims.
Third-party billing services and clearinghouses handling institutional claim capture and electronic transmission.

Accurate completion helps reduce rework and supports timely payer adjudication and audit readiness and appeals management.

Step-by-step: preparing and submitting a UB-04

Follow these steps to complete and submit a UB-04 for electronic or paper claims to payers.

01

Gather Records: Assemble medical records, admission notes, and charge master entries.
02

Complete Fields: Enter header, patient, service lines, and payer info.
03

Validate Codes: Confirm ICD-10 and CPT/HCPCS accuracy and modifiers.
04

Submit Claim: Transmit via clearinghouse or payer portal and retain proof.

Essential sections to complete on a professional UB-04

Core sections of a professional UB-04 ensure accurate claim content, consistent coding, and clear payer instructions for institutional billing and audit support.

Header

Enter provider name, billing provider number, tax ID, billing address, and form locator information exactly as on file with payers; mismatches commonly trigger rejections or requests for corrected claims.

Patient

Record patient name, date of birth, insurance ID, and patient status; include admission and discharge dates and responsible party details to support eligibility and coverage validation during adjudication.

Service Lines

List revenue center codes, units, HCPCS/CPT where required, service dates, and charge amounts; ensure units and modifiers match medical records and facility charge master entries.

Diagnosis/Procedure

Populate principal and secondary diagnosis codes using ICD-10-CM conventions and list procedures with accurate dates, CPT/HCPCS, and modifiers to justify medical necessity and DRG assignment.

Payer Info

Provide primary, secondary, and tertiary payer details with billing sequence codes, subscriber information, and any prior authorization numbers to prevent coordination-of-benefits denials.

Certification

Include authorized signature or electronic certification, billing contact, and payment address; attestations must match provider enrollment records to avoid payor audits.

Common electronic workflow settings for UB-04 submissions

Typical electronic UB-04 workflow settings for clearinghouse submission or EHR export to ensure consistent mapping and payer compatibility.

Field	Configuration
Patient Demographics	EMR to UB-04 mapping; DOB MM/DD/YYYY
Diagnosis Codes	ICD-10 mapping; code position and priority
Service Lines	Revenue code mapping; charge master sync
Submission Method	X12 837I \| clearinghouse \| payer portal

Platform and integration requirements for eSubmission

Platform considerations for electronic UB-04 workflows include file formats, integration endpoints, and authentication methods.

Formats: PDF, DOCX, or EHR export supported
Integrations: Salesforce, NetSuite, Microsoft 365, Google Workspace
Authentication: Email, SMS OTP, and advanced signer authentication

How the UB-04 lifecycle works from prep to remittance

End-to-end UB-04 lifecycle outlining preparation, claim submission, payer adjudication, and remittance reconciliation steps for institutional providers.

Prepare: Compile records, assign ICD-10/CPT codes, and capture charges.
Validate: Run edits and scrubbers to reduce errors and incomplete lines.
Submit: Send via clearinghouse or direct payer portal with supporting attachments.
Reconcile: Match remittance advice to billed charges and post payments.

Best practices to reduce UB-04 denials and speed payment

Practical best practices help minimize denials, improve coding accuracy, and accelerate UB-04 claim throughput and reimbursement.

Confirm Provider Enrollment

Verify provider billing NPI, tax ID, and payer enrollment before submission; mismatched enrollment records are a frequent cause of automated denials and delayed payments and complicate appeals.

Standardize Charge Master Mapping

Maintain an audited charge master that maps revenue codes to billable services consistently across units; regular reconciliation reduces mismatches between billed amounts and medical record documentation during audits.

Automate Code Validation

Use claim scrubbers and code validation tools to catch invalid ICD-10, CPT/HCPCS, or modifier combinations before submission; automated checks lower resubmission rates and reduce manual review workload.

Maintain Supporting Documentation

Keep contemporaneous medical records, prior authorization approvals, and orders linked to the UB-04 claim; timely access to documentation is critical for responding to payer audits and preventing recoupment.

How organizations use e-sign and electronic workflows with institutional claims

Real-world examples show how electronic workflows can streamline documentation and signature capture for clinical and administrative staff.

Fertility Centers of Illinois

The clinic standardized online patient intake to collect signatures and authorization quickly.

Improved signature collection and API integration.
John Butler, Founder, said: "The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Optica Ventures LLC

Optica moved customer-facing agreements online to shorten execution cycles.

Faster execution and ease of use.
Brian Fitzgibbons, COO, said: "The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers."

High-level eSignature pricing and capabilities for institutional workflows

A concise pricing and capability comparison to help evaluate common eSignature providers for UB-04 and related document workflows.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	Yes, 7-day trial	No	No	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 env/user/yr	Varies	Varies	Varies

Security and compliance features to protect UB-04 data

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

Certifications: SOC 2 Type II, ISO 27001, PCI DSS

HIPAA: BAA available; supports protected health information

Audit Trail: Full event log with IP, timestamps, and signer actions

Access Controls: Role‑based access, SSO, and administrative controls

Retention: Tamper-evident records and exportable audit logs

Consequences and risks of incorrect UB-04 submissions

Denials: Claims returned for missing or invalid data

Payment Delays: Adjudication postponed until corrections received

Overpayment Recoupment: Payor recovery for unsupported services

Audit Exposure: CMS or payer audits with documentation requests

FCA Risk: False Claims Act liability for false billing

State Sanctions: Licensing or civil penalties possible

Typical timelines and expectations for UB-04 processing

Key timelines for UB-04 claims include payer timely-filing limits, internal coding and audit deadlines, and remittance reconciliation windows.

Timely-Filing:

Submit within payer limits; frequently 12 months from service date

Claim Adjudication:

Payer decision often within 30–60 days after complete submission

Appeals Window:

Most payers allow appeals within 120 days of denial

Refund Recoupment:

Recoupments often occur within 1–2 remittance cycles post-audit

Recordkeeping:

Retain documentation per payer and legal retention rules

FAQs and troubleshooting for common UB-04 issues

Answers to frequent questions about completing, submitting, and correcting UB-04 claims, with practical steps to resolve common problems.

Need help? Contact support

What is the UB-04 used for?
The UB-04 documents institutional facility charges, patient details, diagnosis and procedure codes, and payer data for Medicare, Medicaid, and commercial payers; it supports claims adjudication and audit trails.
How do I correct a submitted claim?
Follow the payer's corrected claim process—usually submit a replacement claim with corrected fields and a remark code or use the payer's electronic adjustment workflow; retain documentation of the correction and original submission.
Can the UB-04 be electronically signed?
Yes; electronic signatures are legally valid under ESIGN and UETA when intent, consent, attribution, and retention are satisfied. For PHI, ensure a HIPAA BAA with the eSignature provider.
Which attachments are required?
Attach supporting clinical documentation, prior authorizations, and itemized bills per payer instructions; requirements vary by payer and service type, so consult payer-specific guidances.
Who can sign the UB-04?
An authorized billing representative or delegated signatory listed on provider enrollment records should sign or certify; signatures must align with enrollment to avoid audit disputes.
How long until payment?
Adjudication time varies by payer and claim completeness; complete claims often adjudicate within 30–60 days, but unresolved edits or audits can extend timelines significantly.

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