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Provider Manual

UB-04 Instructions and Sample Claim Form

Last Updated on November 26, 2018

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

To access the sample claim form, click the link below and view page 18. 
UB-04 Sample Claim Form

General Information:

The Security Health Plan Processing System is designed to process standard health insurance claim forms (UB-04) using Revenue Codes, Health Care Common Procedure Coding System (HCPCS) with appropriate modifiers and ICD-10-CM Diagnosis Codes.

Refer to the following resource for guidelines on completing the UB-04:

Security Health Plan considers a claim complete when the following data elements are submitted (numbered as shown on the claim form).

Form Locator (FL)
Italics indicate that FL fields are situational

FL1: Provider name, address and telephone number – Enter the name and the complete physical address of the provider submitting the claim. The minimum requirement is the provider name, city, state, and ZIP+4. Do not enter a PO Box or a Zip+4 associated with a PO Box. The name FL 1 should correspond with the NPI in FL56.

BadgerCare:  See specifics in BadgerCare Provider Validation for Claim Processing

FL2: Pay to or Billing Address - Name of the provider and address where payment should be mailed.

FL3a: Patient Control Number - identified and assigned by provider

FL3b: Medical Record Number

FL4: Type of Bill - The first digit of the three-digit number identifies the type of facility, the second digit classifies the type of care being billed, and the third digit indicates the sequence of the bill for a specific episode of care.

FL5: Federal Tax Number - number assigned to the provider by the federal government for tax purposes. Should be reported as XX-XXXXXXX.

FL6: Statement Covers Period - Used for reporting the beginning and ending dates of service.

FL7: Not Required

FL8a: Patient ID – Patient identifier as assigned by Security Health Plan. Only report if different than the subscriber identifier in FL60.

FL8b: Patient Last Name, First Name, Middle Initial

FL9a-e: Patient Address
          Street Address
          City
          State
          Zip
          Country Code

FL10: Patient Birthdate – MMDDYYYY

FL11: Patient Sex – M=male; F=female; U=unknown

FL12: Admission Date – Date the patient was admitted or the start date for the episode of care (MMDDYY)

FL13: Admission Hour – The hour in which the patient entered the facility. Enter in military time using two numeric characters

FL14: Type of Admission/Visit – 1 alphanumeric character that indicates the priority of admission/visit

FL15: Source of Admission – 1 alphanumeric character that indicates the source of admission or service

FL16: Discharge Hour – The hour in which the patient was discharged from inpatient. Enter in military time using two numeric characters

FL17: Patient Discharge Stat – 2 numeric characters that indicates the patient’s discharge status at the ending date of service

FL18-28: Condition Codes – 2 alphanumeric characters that identify conditions that may affect payer processing

FL29: Accident State – 2 digit character abbreviation of the state where the accident occurred (ie: WI)

FL30: Not Required

FL31-34: Occurrence Codes and Dates – 2 alphanumeric characters that identify a significant event related to this claim. Date entered in MMDDYY

FL35-36: Occurrence Span Codes and Dates – 2 alphanumeric characters that identify an event that relates to payment of the claim. These codes identify occurrences that happened over a span of time. Date entered in MMDDYY in each field

FL37: Not Required

FL38: Responsible Party Name and Address

FL39-41: Value Codes and Amounts – 2 alphanumeric characters that identify data elements that are necessary to process the claim and related dollar amounts or values

FL42: Revenue Code – Report the appropriate revenue code to identify a specific accommodation and/or ancillary service. There is no “Total” line in the charge area. Enter revenue code 0001 as the last line with the sum of the charges billed.

FL43: Revenue Description - A description or standard abbreviation for each revenue code reported

FL44: HCPCS/Rates/HIPPS Rates Codes – The HCPCS applicable to ancillary services for outpatient claims (required), the HIPPS rate code or the accommodation rate for inpatient claims.

FL45: Service Date – The date on which the indicated service was provided. Date entered in MMDDYY

FL46: Service Units - A quantitative measure of services rendered including items such as the number of accommodation days, visits, miles, pints of blood, units of treatments

FL47: Total Charges (by revenue code) – Total charge per line

FL48: Noncovered Charges – Total noncovered charge of the service line

FL49: Not Required

FL50: Payer Name – Name of each health plan for which the provider might expect some payment for the bill. Line A = primary payer, line B = secondary payer, line C = tertiary payer

FL51: Health Plan ID – The number used to identify the payer or health plan

FL52: Rel. Info  – indicates whether the provider has a signed statement from the patient or patient’s legal representative permitting the provider to release data to other organizations in order to adjudicate the claim. This indicator applies to the payers listed in FL50 on lines A, B, and C.

FL53: Asg. Ben. – This field shows whether the provider has a signed form authorizing the third-party insurer to pay the provider directly for the service. This indicator applies to the payers listed in FL50 on lines A, B, and C.

FL54: Prior payments – represents payments received from payers in FL50 on lines A, B, C

FL55: Est. Amount Due – represents an estimate by the hospital of the amount due from the indicated payer in FL50 on lines A, B, and C.

FL56: NPI – Unique identification number assigned to provider submitting the bill

FL57: Other Prv ID – Not Required

FL58: Insured’s Name – Name of the patient or insured individual in whose name the insurance is issued as qualified by the payer organization listed in FL 50 on lines A,  B, and C.

FL59: P. Rel – two alpha-numeric character code that indicates the relationship to the insured individual identified in FL 58 on lines A,  B, and C.

FL60: Insured’s Unique ID - The insured’s identification number assigned by the payer organization. This field allows 20 alphanumeric characters in three lines.

FL61: Group Name - The group or plan through which the health insurance coverage is provided to the insured.

FL62: Insurance Group No. - The identification number, control number or code that is assigned by the insurance company or claims administrator to identify the group under which the individual is covered.

FL63: Treatment Authorization Codes - A number or other indicator that designates that the treatment covered by this bill has been authorized by the payer indicated in FL 50 on lines A, B, and C.

FL64: Document Control Number (DCN) – payer’s internal control number assigned to the bill as part of the payer’s internal control process. Providers requesting an adjustment to a previously processed claim (TOB 0XX7 in FL4) must provide the DCN of the claim to be adjusted.

FL65: Employer Name – Name of employer that provides or may provide health care coverage for the insured individual identified in FL58 on lines A, B, and C

FL66: DX – Identifies the version of the ICD being reported

FL67: Principal Diagnosis Code - The full ICD-10-CM diagnosis code, including the fourth and fifth digits, if applicable, that describes the principal diagnosis (the condition established after study to be chiefly responsible for causing the hospitalization or use of other hospital services). Present on admission indicator (POA) should be indicated in the field on the far right following the code.

BadgerCare: POA requirements - refer to ForwardHealth Topic # 8257.

FL67 A-Q: Other Diagnosis Code - This field contains the full ICD-10-CM diagnosis codes, including the fourth and fifth digits, if applicable, corresponding to all conditions that coexist at the time of admission, that develop subsequently or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode that has no bearing on the current hospital stay should be excluded. Present on admission indicator (POA) should be indicated in the field on the far right following the code.

FL68: Not Required

FL69: Admit DX – This field is for reporting the complete ICD-10-CM diagnosis code, including the fourth and fifth digits when appropriate, describing the patient’s diagnosis or reason for visit at the time of admission or outpatient registration.

FL70: Patient Reason DX – reporting the complete ICD – 10- CM diagnosis code, including the fourth and fifth digits when appropriate, describing the patient’s reason for visit at the time of outpatient registration.

FL71: PPS Code – Identifies the DRG assigned to the claim based on the grouper software

FL72: ECI – External cause of injury code. Contains up to 3 full ICD-10-CM diagnosis codes, including the fourth and fifth digits when appropriate, pertaining to the external cause of injury, poisoning, or adverse effect

FL73: Not Required

FL74: Principal Procedure Code/Date - The ICD-10-PCS for the principal procedure performed during the period covered by the bill and the date on which the principal procedure described on the bill was performed. For inpatient and home IV therapy services, if surgery is performed during the inpatient stay from which the course of therapy is initiated.

FL74 A-E: Other procedure codes and dates - This field allows reporting of up to five ICD-10-PCS to identify the significant procedures performed during the billing period, other than the principal procedure, and the corresponding dates when the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis. For inpatient and home IV therapy services, if surgery is performed during the inpatient stay from which the course of therapy is initiated. Enter the codes in these fields in descending order of importance.

FL75: Not Required

FL76: Attending Provider Name/NPI – individual who has overall responsibility for the patient’s medical care and treatment reported on this claim.

FL77: Operating Provider Name/NPI – individual with the primary responsibility for performing the surgical procedure

FL78-79: Other Provider Name/NPI – provider that corresponds to the indicated provider type on this claim

FL80: Remarks – additional information necessary to adjudicate claim

FL81: CC (code-code) – report overflow or additional codes related to field locators or to report externally maintained codes approved by the NUBC for inclusion in the institutional data set

Electronic claim submission:

Electronic Payer ID: 39045

For specific information regarding electronic claims submission, please see ‘Electronic Claims Submission’ Topic.

Paper claim submission:

Paper claims can be mailed to:
          Security Health Plan
          P.O. Box 8000
          Marshfield, WI 54449-8000

Security Health Plan uses optical character recognition (OCR) software when processing paper claims. OCR software processes claim forms by reading text within fields on the claim form utilizing scanners to create an image. This software speeds paper claim processing if claim forms are completed correctly. Tips for submitting error-free paper claim submission:

  • Use only a CMS 1500 (02-12) red and white claim form – claim forms that are black and white may darken upon scanning resulting in certain fields to be un-readable, resulting in claim denials
  • Use black ink only
  • Required information must be filled in completely, accurately, and legibly.
  • Accurately align text within the individual fields on the claim form
  • Do not highlight data on the claim form; this shows as black on the scanned image
  • Do not staple, clip, or tape anything to the claim form
  • All attachments should be one sided; do not print double sided
  • If submitting an attachment intended for claim forms, please put a copy of the attachment behind each claim form
  • Place all necessary documentation in the envelope behind the claim form on a 8 x 11 sheet of paper; do not submit additional notes on post-its or paper size smaller than 8x11