UB-04 Claim Form - General Instructions

The UB-04 claim form is a hard-copy facility claim form recently redesigned to accommodate various changes to facility claims filing necessitated by current and upcoming governmental initiatives. Although the form is similar in appearance to the older version of the facility claim form, UB-92, a number of fields have been moved or expanded and new fields have been added.

HMSA has determined that it will use the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual as the standard source for codes and code descriptions to be entered in the various form locators (FL). However, in some cases, HMSA varies from NUBC directions concerning whether a specific field is required or how the data is to be entered in a specific field.

Information on ordering the NUBC Official UB-04 Data Specifications Manual and how to become a NUBC subscriber is available on the NUBC website, nubc.org.

HMSA encourages facility providers to review the attached documentation carefully and to follow the directions found therein. Doing so will ensure that facilities' claims are processed expeditiously and will decrease the possibility of processing errors.

Below is a link to HMSA's interactive version of the UB-04 claim form. The document includes instructions applicable to all HMSA lines of business. Adobe Reader or another PDF reader application is required to view the form. Please note that providers may not submit claims on printouts of the interactive form.  Any claims submitted on printouts of the interactive form will be rejected.

UB-04 - HMSA Data Requirements by Field [PDF]
Note: You must download the form to experience its interactive features.

Using the Form

To review the instructions for a particular FL, simply click on the colored circle that surrounds the field number. A text window containing the FL instructions will appear on the screen. Instructions also appear, in a truncated format as the cursor moves over a particular field. However, clicking on the FL number displays the instructions in a more user-friendly way.

Move a field's instructions by clicking at the top or bottom and drag (moving the mouse while holding down the left mouse button). To resize the window, click in the lower right corner and drag. Changes will be retained until the PDF-reader application is closed.

Revision History