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UB-04 Billing Instructions

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

All claims from participating providers that are Health Net's responsibility must be submitted to Health Net Medi-Cal or Cal MediConnect claims within 180 days from the last day of the month of the date services were rendered. EPO, HMO, HSP, Medicare Advantage, and PPO participating providers must be submitted claims to Health Net within 120 days from the date services were rendered, unless a different time frame is stated in the providers' contract. Health Net accepts claims submitted on the standard CMS-1500 and UB-04 form and computer generated claims using these formats.

Field number

Field description

Instruction or comments

Required, conditional or not required

1

Unlabeled field

Line 1: Enter the complete provider name. Line 2: Enter the complete mailing address. Line 3: Enter the city, state, and ZIP +4 Codes (include hyphen). Note: The 9 digit ZIP (ZIP +4 codes) is a requirement for paper and EDI claims. Line 4: Enter the area code and telephone number

**ALERT: Providers submitting paper claims should left-align data in this field.

Required

2

Unlabeled field

Enter the pay-to name and address

Not required

3a

Patient control no

Enter the facility patient account/control number

Not required

3b

Medical record number

Enter the facility patient medical or health record number

Required

4

Type of bill

Enter the appropriate type of bill (TOB) code as specified by the NUBC UB-04 Uniform Billing Manual minus the leading "0" (zero). A leading "0" is not needed. Digits should be reflected as follows:

1st Digit - Indicating the type of facility. 2nd Digit - Indicating the type of care. 3rd Digit- Indicating the bill sequence (frequency code).

Required

5

Fed Tax No

Enter the nine-digit number assigned by the federal government for tax reporting purposes

Required

6

Statement covers period from/through

Enter begin and end, or admission and discharge dates, for the services billed. Inpatient and outpatient observation stays must be billed using the admission date and discharge date. Outpatient therapy, chemotherapy, laboratory, pathology, radiology, and dialysis may be billed using a date span. All other outpatient services must be billed using the actual date of service (MMDDYY).

Required

7

Unlabeled field

Not used.

Not required

8a

Patient name

8a - Enter the first nine digits of the identification number on the member's ID card.

Not required

8b

Enter the patient's last name, first name, and middle initial as it appears on the ID card. Use a comma or space to separate the last and first names.

Titles: (Mr., Mrs., etc.) should not be reported in this field.

Prefix: No space should be left after the prefix of a name (e.g., McKendrick. H).

Hyphenated names: Both names should be capitalized and separated by a hyphen (no space).

Suffix: a space should separate a last name and suffix.

Enter the patient's complete mailing address.

Required

9

Patient address

Enter the patient's complete mailing address.

Line a: Street address Line b: City Line c: State Line d: ZIP code Line e: Country code (NOT REQUIRED)

Required - Except line 9e county code

10

Birthdate

Enter the patient's date of birth (MMDDYYYY)

Required - Ensure DOB of patient is entered and not the insured)

11

Sex

Enter the patient's sex. Only M or F is accepted

Required

12

Admission date

Enter the date of admission for inpatient claims and date of service for outpatient claims (MMDDYY)

Required for Inpatient claims. Leave blank for Outpatient claims.

Exceptions: Type of bill codes 012x, 022x, 032x, 034x, 081x, and 082x require boxes 12–13 to be populated.

13

Admission hour

Enter the time using two-digit military time (00-23) for the time of inpatient admission or time of treatment for outpatient services.

  • 00 - 12:00 a.m. 01 - 1:00 a.m.
  • 02 - 2:00 a.m. 03 - 3:00 a.m.
  • 04 - 4:00 a.m. 05 - 5:00 a.m.
  • 06 - 6:00 a.m. 07 - 7:00 a.m.
  • 08 - 8:00 a..m 09 - 9:00 a.m.
  • 10 - 10:00 a.m. 11 - 11:00 a.m.
  • 12 - 12:00 p.m. 13 - 1:00 p.m.
  • 14 - 2:00 p.m. 15 - 3:00 p.m.
  • 16 - 4:00 p.m. 17 - 5:00 p.m.
  • 18 - 6:00 p.m. 19 - 7:00 p.m.
  • 20 - 8:00 p.m. 21 - 9:00 p.m.
  • 22 - 10:00 p.m. 23 - 11:00 p.m.

Required for Inpatient claims. Leave blank for Outpatient claims.

Exceptions: Type of bill codes 012x, 022x, 032x, 034x, 081x, and 082x require boxes 12–13 to be populated.

14

Admission type

Require for inpatient and outpatient admissions. Enter the one-digit code indicating the type of the admission using the appropriate following codes:

  • 1 - Emergency
  • 2 - Urgent
  • 3 - Elective
  • 4 - Newborn
  • 5 - Trauma

Required

15

Admission source

Required for inpatient and outpatient admissions. Enter the one-digit code indicating the source of the admission or outpatient service using one of the following codes.

For type of admission 1,2,3, or 5:

  • 1 - Physician referral
  • 2 - Clinic referral
  • 3 - Health maintenance referral (HMO)
  • 4 - Transfer from a hospital
  • 5 - Transfer from skilled nursing facility
  • 6 - Transfer from another health care facility
  • 7 - Emergency room
  • 8 - Court/law enforcement
  • 9 - Information not available

For type of admission 4 (newborn):

  • 1 - Normal delivery
  • 2 - Premature delivery
  • 3 - Sick baby
  • 4 - Extramural birth
  • Information not available

Required

16

Discharge hour

Enter the time using two-digit military times (00-23) for the time of the inpatient or outpatient discharge.

  • 00 - 12:00 a.m. 01 - 1:00 a.m.
  • 02 - 2:00 a.m. 03 - 3:00 a.m.
  • 04 - 4:00 a.m. 05 - 5:00 a.m.
  • 06 - 6:00 a.m. 07 - 7:00 a.m.
  • 08 - 8:00 a.m 09 - 9:00 a.m.
  • 10 - 10:00 a.m. 11 - 11:00 a.m.
  • 12 - 12:00 p.m. 13 - 1:00 p.m.
  • 14 - 2:00 p.m. 15 - 3:00 p.m.
  • 16 - 4:00 p.m. 17 - 5:00 p.m.
  • 18 - 6:00 p.m. 19 - 7:00 p.m.
  • 20 - 8:00 p.m. 21 - 9:00 p.m.
  • 22 - 10:00 p.m. 23 - 11:00 p.m.

Conditional - Enter the time using two-digit military times (00-23) for the time of the inpatient or outpatient discharge

17

Patient status

REQUIRED for inpatient and outpatient claims. Enter the two-digit disposition of the patient as of the "through" date for the billing period listed in field 6 using one of the following codes:

  • 01 - Routine discharge
  • 02 - Discharged to another short-term general hospital
  • 03 - Discharged to SNF
  • 04 - Discharged to ICF
  • 05 - Discharged to another type of institution
  • 06 - Discharged to care of home health service organization
  • 07 - Left against medical advice
  • 09 - Discharged/transferred to home under care of a home IV provider
  • 09 - Admitted as an inpatient to this hospital (only for use on Medicare outpatient hospital claims)
  • 20 - Expired or did not recover
  • 30 - Still patient (To be used only when the client has been in the facility for 30 consecutive days if payment is based on DRG)
  • 40 - Expired at home (hospice use only)
  • 41 - Expired in a medical facility (hospice use only)
  • 42 - Expired-place unknown (hospice use only)
  • 43 - Discharged/transferred to a federal hospital (such as a Veteran's Administration [VA] hospital)
  • 50 - Hospice-Home
  • 51 - Hospice-Medical Facility
  • 61 - Discharged/transferred within this institution to a hospital-based Medicare approved swing bed
  • 62 - Discharged/transferred to an Inpatient rehabilitation facility (IRF), including rehabilitation distinct part units of a hospital
  • 63 - Discharged/transferred to a Medicare certified long-term care hospital (LTCH)
  • 64 - Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare
  • 65 - Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital
  • 66 - Discharged/transferred to a critical access hospital (CAH)

Required

18-28

Condition codes

REQUIRED when applicable. Condition codes are used to identify conditions relating to the bill that may affect payer processing.

Each field (18-24) allows entry of a two-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes).

For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual

Conditional

REQUIRED when condition codes are used to identify conditions relating to the bill that may affect payer processing

29

Accident state

N/A

Not required

30

Unlabeled Field

N/A

Not required

31-34 a-b

Occurrence code and occurrence date

Occurrence code: REQUIRED when applicable. Occurrence Codes are used to identify events relating to the bill that may affect payer processing.

Each field (31-34a) allows for entry of a two-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes).

For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual.

Occurrence date: REQUIRED when applicable or when a corresponding occurrence code is present on the same line (31a-34a). Enter the date for the associated occurrence code in MMDDYY format

Conditional

REQUIRED when occurrence codes are used to identify events relating to the bill that may affect payer processing

35-36 a-b

Occurrence SPAN code and Occurrence date

Occurrence span code: REQUIRED when applicable. Occurrence codes are used to identify events relating to the bill that may affect payer processing.

Each field (35-36a) allows for entry of a two-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes).

For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual.

Occurrence span date: REQUIRED when applicable or when a corresponding occurrence span code is present on the same line (35a-36a). Enter the date for the associated occurrence code in MMDDYY format.

Conditional

REQUIRED when occurrence codes are used to identify events relating to the bill that may affect payer processing

37

Unlabeled field

REQUIRED for re-submissions or adjustments. Enter the DCN (document control number) of the original claim

Conditional

REQUIRED for resubmissions or adjustments. Enter the DCN (document control number) of the original claim

38

Responsible party name and address

N/A

Not required

39-41 a-d

Value codes and amounts

Code: REQUIRED when applicable. Value codes are used to identify events relating to the bill that may affect payer processing. Each field (39-41) allows for entry of a two-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes).

Up to 12 codes can be entered. All "a" fields must be completed before using "b" fields, all "b" fields before using "c" fields, and all "c" fields before using "d" fields.

For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual.

Amount: REQUIRED when applicable or when a value code is entered. Enter the dollar amount for the associated value code. Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e., 199,999.99). Do not enter a dollar sign ($) or a decimal. A decimal is implied. If the dollar amount is a whole number (i.e., 10.00), enter 00 in the area to the right of the vertical line

Conditional

REQUIRED when value codes are used to identify events relating to the bill that may affect payer processing

42 Lines 1-22

REV CD

Enter the appropriate revenue codes itemizing accommodations, services, and items furnished to the patient. Refer to the NUBC UB-04 Uniform Billing Manual for a complete listing of revenue codes and instructions.

Enter accommodation revenue codes first followed by ancillary revenue codes. Enter codes in ascending numerical value

Required

42 Line 23

Rev CD

Enter 0001 for total charges.

Required

43 Lines 1-22

Description

Enter a brief description that corresponds to the revenue code entered in the service line of field 42

Required

43 Line 23

PAGE ___ OF ___

Enter the number of pages. Indicate the page sequence in the "PAGE" field and the total number of pages in the "OF" field. If only one claim form is submitted, enter a "1" in both fields (i.e., PAGE "1" OF "1"). (Limited to 4 pages per claim)

Conditional - Enter the number of pages. (Limited to 4 pages per claim)

44 lines 1-22

HCPCS/Rates

REQUIRED for outpatient claims when an appropriate CPT/HCPCS code exists for the service line revenue code billed. The field allows up to nine characters. Only one CPT/HCPCS and up to two modifiers are accepted. When entering a CPT/HCPCS with a modifier(s), do not use spaces, commas, dashes, or the like between the CPT/HCPCS and modifier(s).

Refer to the NUBC UB-04 Uniform Billing Manual for a complete listing of revenue codes and instructions.

Please refer to your current provider contract

Conditional

REQUIRED for outpatient claims when an appropriate CPT/HCPCS code exists for the service line revenue code billed

45 Lines 1-22

Service date

REQUIRED on all outpatient claims. Enter the date of service for each service line billed (MMDDYY). Multiple dates of service may not be combined for outpatient claims

Conditional

REQUIRED on all outpatient claims. Enter the date of service for each service line billed (MMDDYY). Multiple dates of service may not be combined for outpatient claims

45 Line 23

Creation date

Enter the date the bill was created or prepared for submission on all pages submitted (MMDDYY).

Required

46 lines 1-22

Service units

Enter the number of units, days, or visits for the service. A value of at least "1" must be entered. For inpatient room charges, enter the number of days for each accommodation listed

Required

47 Lines 1-22

Total charges

Enter the total charge for each service line

Required

47 Line 23

Totals

Enter the total charges for all service lines

Required

48 Lines 1-22

Non-covered charges

Enter the non-covered charges included in field 47 for the revenue code listed in field 42 of the service line. Do not list negative amounts

Conditional - Enter the noncovered charges included in field 47 for the revenue code listed in field 42 of the service line. Do not list negative amounts

48 Line 23

Totals

Enter the total non-covered charges for all service lines

Conditional - Enter the total noncovered charges for all service lines

49

Unlabeled field

Not used

Not required

50 A-C

Payer

Enter the name of each payer from which reimbursement is being sought in the order of the payer liability.

Line A refers to the primary payer; B, secondary; and C, tertiary

Required

51 A-C

Health plan identification number

N/A

Not required

52 A-C

REL information

REQUIRED for each line (A, B, C) completed in field 50. Release of Information Certification Indicator. Enter 'Y' (yes) or 'N' (no). Providers are expected to have necessary release information on file. It is expected that all released invoices contain 'Y'

Required

53

ASG. BEN.

Enter 'Y' (yes) or 'N' (no) to indicate a signed form is on file authorizing payment by the payer directly to the provider for services

Required

54

Prior payments

Enter the amount received from the primary payer on the appropriate line

Conditional - Enter the amount received from the primary payer on the appropriate line when Health Net is listed as secondary or tertiary

55

EST amount due

N/A

Not required

56

National Provider Identifier or provider ID

REQUIRED: Enter providers 10-character NPI ID

Required

57

Other provider ID

Enter the numeric provider identification number.

Enter the TPI number (non-NPI number) of the billing provider

Required

58

Insured's name

For each line (A, B, C) completed in field 50, enter the name of the person who carries the insurance for the patient. In most cases this will be the patient's name. Enter the name as last name, first name, middle initial

Required

59

Patient relationship

N/A

Not required

60

Insured unique ID

REQUIRED: Enter the patient's insurance ID exactly as it appears on the patient's ID card. Enter the insurance ID in the order of liability listed in field 50

Required

61

Group name

N/A

Not required

62

Insurance group no.

N/A

Not required

63

Treatment authorization code

Enter the prior authorization or referral when services require precertification

Conditional - Enter the prior authorization or referral when services require precertification

64

Document control number

Enter the 12-character original claim number of the paid/denied claim when submitting a replacement or void on the corresponding A, B, C line

Applies to claim submitted with a type of bill (field 4), frequency of "7" (replacement of prior claim) or type of bill, frequency of "8" (void/cancel of prior claim).

*Please refer to the reconsider/corrected claims section

Conditional - Enter the 12-character original claim number of the paid/denied claim when submitting a replacement or void on the corresponding A, B, C line reflecting Payer from field 50

65

Employer name

N/A

Not required

66

DX version qualifier

N/A

Required

67

Principal diagnosis code

Enter the principal/primary diagnosis or condition using the appropriate release/update of ICD-10-CM Volume 1 & 3 for the date of service

Required

67

A-Q

Other diagnosis code

Enter additional diagnosis or conditions that coexist at the time of admission or that develop subsequent to the admission and have an effect on the treatment or care received using the appropriate release/update of ICD-10CM Volume 1 & 3 for the date of service.

Diagnosis codes submitted must be valid ICD-10 Codes for the date of service and carried out to its highest level of specificity - 4th or 5th digit. "E" and most "V" codes are NOT acceptable as a primary diagnosis.

Note: Claims with incomplete or invalid diagnosis codes will be denied

Conditional - Enter additional diagnosis or conditions that coexist at the time of admission

68

Present on admission indicator

 

Required

69

Admitting diagnosis code

Enter the diagnosis or condition provided at the time of admission as stated by the physician using the appropriate release/update of ICD-10-CM Volume 1 & 3 for the date of service.

Diagnosis codes submitted must be valid ICD-10 codes for the date of service and carried out to its highest level of specificity - 4th or 5th digit. "E" codes and most "V" are NOT acceptable as a primary diagnosis.

Note: Claims with missing or invalid diagnosis codes will be denied

Required

70

Patient reason code

Enter the ICD-10-CM code that reflects the patient's reason for visit at the time of outpatient registration. Field 70a requires entry; fields 70b-70c are conditional.

Diagnosis codes submitted must be valid ICD-10 codes for the date of service and carried out to its highest digit - 4th or 5th. "E" codes and most "V" codes are NOT acceptable as a primary diagnosis.

NOTE: Claims with missing or invalid diagnosis codes will be denied

Required

71

PPS/DRG code

N/A

Not required

72 a, b, c

External cause code

N/A

Not required

73

Unlabeled field

N/A

Not required

74

Principal procedure code/date

CODE: Enter the ICD-10 procedure code that identifies the principal/primary procedure performed. Do not enter the decimal between the 2nd or 3rd digits of code; it is implied. DATE: Enter the date the principal procedure was performed (MMDDYY).

Conditional - Enter the ICD-10 procedure code that identifies the principal/primary procedure performed. Do not enter the decimal between the 2nd or 3rd digits of code; it is implied. DATE: Enter the date the principal procedure was performed (MMDDYY)

74 a-e

Other procedure code date

REQUIRED on inpatient claims when a procedure is performed during the date span of the bill.

CODE: Enter the ICD-10 procedure code(s) that identify significant procedure(s) performed other than the

principal/primary procedure. Up to five ICD-10 procedure codes may be entered. Do not enter the decimal; it is implied.

DATE: Enter the date the principal procedure was performed (MMDDYY).

Conditional

REQUIRED on inpatient claims when a procedure is performed during the date span of the bill

75

Unlabeled field

N/A

Not required

76

Attending physician

Enter the NPI and name of the physician in charge of the patient care.

  • NPI: Enter the attending physician 10-character NPI ID.
  • Taxonomy code: Enter valid taxonomy code.
  • QUAL: Enter one of the following qualifier and ID number:
  • 0B - State license #.
  • 1G - Provider UPIN.
  • G2 - Provider commercial #.
  • B3 - Taxonomy code.
  • LAST: Enter the attending physician's last name.
  • FIRST: Enter the attending physician's first name

Required

77

Operating physician

REQUIRED when a surgical procedure is performed.

Enter the NPI and name of the physician in charge of the patient care.

  • NPI: Enter the attending physician 10-character NPI ID.
  • Taxonomy code: Enter valid taxonomy code.
  • QUAL: Enter one of the following qualifier and ID number:
  • 0B - State license #.
  • 1G - Provider UPIN.
  • G2 - Provider commercial #.
  • B3 - Taxonomy code.
  • LAST: Enter the attending physician's last name.
  • FIRST: Enter the attending physician's first name.

Conditional

REQUIRED when a surgical procedure is performed. Enter the NPI and name of the physician in charge of the patient care

78 & 79

Other physician

Enter the provider type qualifier, NPI and name of the physician in charge of the patient care.

  • (Blank Field): Enter one of the following provider type qualifiers:
  • DN - Referring provider.
  • ZZ - Other operating MD.
  • 82 - Rendering provider.
  • NPI: Enter the other physician 10-character NPI ID.
  • QUAL: Enter one of the following qualifier and ID number, or 0B - State license number
  • 1G - Provider UPIN number
  • G2 - Provider commercial number

Conditional

80

Remarks

N/A

Not required

81

CC

A: Taxonomy of billing provider. Use B3 qualifier.

Required

82

Attending Physician

Enter name or seven-digit provider number of ordering physician

Required

Last Updated: 07/01/2024