Currently approved UB04 Data Elements

Attachment D: Currently Approved UB-04 Data Elements

FL	Description
FL01	[Billing Provider Name]
FL01	[Billing Provider Street Address]
FL01	[Billing Provider City, State, Zip]
FL01	[Billing Provider Telephone, Fax, Country Code]
FL02	[Billing Provider’s Designated Pay-to Name]
FL02	[Billing Provider’s Designated Pay-to Address]
FL02	[Billing Provider’s Designated Pay-to City, State]
FL02	[Billing Provider’s Designated Pay-to ID]
FL03a	Patient Control Number
FL03b	Medical/Health Record Number
FL04	Type of Bill
FL05	Federal Tax Number
FL05	Federal Tax Number
FL06	Statement Covers Period - From/Through
FL07	Unlabeled
FL07	Unlabeled
FL08	Patient Name/ID
FL08	Patient Name
FL09	Patient Address - Street
FL09	Patient Address - City
FL09	Patient Address - State
FL09	Patient Address - ZIP
FL09	Patient Address - Country Code
FL10	Patient Birthdate
FL11	Patient Sex
FL12	Admission/Start of Care Date
FL13	Admission Hour
FL14	Priority (Type) of Admission or Visit
FL15	Point of Origin for Admission or Visit
FL16	Discharge Hour
FL17	Patient Discharge Status
FL18	Condition Code
FL19	Condition Code
FL20	Condition Code
FL21	Condition Code
FL22	Condition Code
FL23	Condition Code
FL24	Condition Code
FL25	Condition Code
FL26	Condition Code
FL27	Condition Code
FL28	Condition Code
FL29	Accident State
FL30	Unlabeled
FL30	Unlabeled
FL31	Occurrence Code/Date
FL31	Occurrence Code/Date
FL32	Occurrence Code/Date
FL32	Occurrence Code/Date
FL33	Occurrence Code/Date
FL33	Occurrence Code/Date
FL34	Occurrence Code/Date
FL34	Occurrence Code/Date
FL35	Occurrence Span Code/From/Through
FL35	Occurrence Span Code/From/Through
FL36	Occurrence Span Code/From/Through
FL36	Occurrence Span Code/From/Through
FL37	Unlabeled
FL37	Unlabeled
FL38	Responsible Party Name/Address
FL38	Responsible Party Name/Address
FL38	Responsible Party Name/Address
FL38	Responsible Party Name/Address
FL38	Responsible Party Name/Address
FL39	Value Code
FL39	Value Code Amount
FL39	Value Code
FL39	Value Code Amount
FL39	Value Code
FL39	Value Code Amount
FL39	Value Code
FL39	Value Code Amount
FL40	Value Code
FL40	Value Code Amount
FL40	Value Code
FL40	Value Code Amount
FL40	Value Code
FL40	Value Code Amount
FL40	Value Code
FL40	Value Code Amount
FL41	Value Code
FL41	Value Code Amount
FL41	Value Code
FL41	Value Code Amount
FL41	Value Code
FL41	Value Code Amount
FL41	Value Code
FL41	Value Code Amount
FL42	Revenue Codes
FL43	Revenue Code Description/IDE Number/Medicaid Drug rebate
FL44	HCPCS/Accommodation Rates/HIPPS Rate Codes
FL45	Service Dates
FL46	Service Units
FL47	Total Charges
FL48	Non-Covered Charges
FL49	Unlabeled
FL50	Payer Identification - Primary
FL50	Payer Identification - Secondary
FL50	Payer Identification - Tertiary
FL51	Health Plan ID
FL51	Health Plan ID
FL51	Health Plan ID
FL52	Release of Information - Primary
FL52	Release of Information - Secondary
FL52	Release of Information - Tertiary
FL53	Assignment of Benefits - Primary
FL53	Assignment of Benefits - Secondary
FL53	Assignment of Benefits - Tertiary
FL54	Prior Payments - Primary
FL54	Prior Payments - Secondary
FL54	Prior Payments - Tertiary
FL55	Estimated Amount Due - Primary
FL55	Estimated Amount Due - Secondary
FL55	Estimated Amount Due - Tertiary
FL56	NPI – Billing Provider
FL57	Other Provider ID
FL57	Other Provider ID
FL57	Other Provider ID
FL58	Insured’s Name - Primary
FL58	Insured's Name - Secondary
FL58	Insured's Name -Tertiary
FL59	Patient’s Relationship - Primary
FL59	Patient's Relationship - Secondary
FL59	Patient's Relationship - Tertiary
FL60	Insured’s Unique ID-Primary
FL60	Insured's Unique ID - Secondary
FL60	Insured's Unique ID - Tertiary
FL61	Insurance Group Name - Primary
FL61	Insurance Group Name - Secondary
FL61	Insurance Group Name -Tertiary
FL62	Insurance Group No. - Primary
FL62	Insurance Group No. - Secondary
FL62	Insurance Group No. - Tertiary
FL63	Treatment Authorization Codes - Primary
FL63	Treatment Authorization Code - Secondary
FL63	Treatment Authorization Code - Tertiary
FL64	Document Control Number (DCN)
FL64	Document Control Number (DCN)
FL64	Document Control Number (DCN)
FL65	Employer Name (of the insured) - Primary
FL65	Employer Name (of the insured) - Secondary
FL65	Employer Name (of the insured) - Tertiary
FL66	Diagnosis and Procedure Code Qualifier (ICD Version Indicator)
FL67	Principal Diagnosis Code and Present on Admission (POA) Indicator
FL67A	Other Diagnosis and POA Indicator
FL67B	Other Diagnosis and POA Indicator
FL67C	Other Diagnosis and POA Indicator
FL67D	Other Diagnosis and POA Indicator
FL67E	Other Diagnosis and POA Indicator
FL67F	Other Diagnosis and POA Indicator
FL67G	Other Diagnosis and POA Indicator
FL67H	Other Diagnosis and POA Indicator
FL67I	Other Diagnosis and POA Indicator
FL67J	Other Diagnosis and POA Indicator
FL67K	Other Diagnosis and POA Indicator
FL67L	Other Diagnosis and POA Indicator
FL67M	Other Diagnosis and POA Indicator
FL67N	Other Diagnosis and POA Indicator
FL67O	Other Diagnosis and POA Indicator
FL67P	Other Diagnosis and POA Indicator
FL67Q	Other Diagnosis and POA Indicator
FL68	Unlabeled
FL68	Unlabeled
L69	Admitting Diagnosis Code
FL70a	Patient Reason for Visit Code
FL70b	Patient Reason for Visit Code
FL70c	Patient Reason for Visit
FL71	Prospective Payment System (PPS) Code
FL72a	External Cause of Injury Code and POA Indicator
FL72b	External Cause of Injury Code and POA Indicator
FL72c	External Cause of Injury Code and POA
FL73	Unlabeled
FL74	Principal Procedure Code/Date
FL74a	Other Procedure Code/Date
FL74b	Other Procedure Code/Date
FL74c	Other Procedure Code/Date
FL74d	Other Procedure Code/Date
FL74e	Other Procedure Code/Date
FL75	Unlabeled
FL75	Unlabeled
FL75	Unlabeled
FL75	Unlabeled
FL76	Attending Provider - NPI/QUAL/ID
FL76	Attending Provider – Last/First
FL77	Operating Physician - NPI/QUAL/ID
FL77	Operating Physician - Last/First
FL78	Other Provider - QUAL/NPI/QUAL/ID
FL78	Other Provider - Last/First
FL79	Other Provider - QUAL/NPI/QUAL/ID
FL79	Other Provider - Last/First
FL80	Remarks
FL80	Remarks
FL80	Remarks
FL80	Remarks
FL81	Code-Code - QUAL/CODE/VALUE
FL81	Code-Code - QUAL/CODE/VALUE
FL81	Code-Code - QUAL/CODE/VALUE
FL81	Code-Code - QUAL/CODE/VALUE