Institutional Claims UB-04 Boxes Field Map

A map of the different EZClaim Field Names and their corresponding boxes on Institutional Claims

Tip: You can find a Printable version of the Field Map here!

UB-04 Boxes (Field Map)

Many of the fields for the UB-04 form need to be added manually to the grids. See Column Chooser for information on adding additional columns.

Field No.	Field Name (EZClaim)	Screen > Field	Notes
1	Provider Name and Address	Claim > Billing Provider
2	Service Facility	Claim > Service Facility
3a	Pat. Cntl #	Claim > Claim ID (or Invoice #)	Will use the Invoice # if available otherwise, the Claim ID.
3b	Med Rec #	Patient > Account #
4	Type of Bill	Claim > Type of Bill
5	Fed. Tax No.	Claim > Billing Provider	Billing Provider Tax ID number as entered into Physician Library.
6	Statement Covers Period		Min and Max of date of services (earliest From date and the last To date) OR the values contained in the Statement From Override and Statement Through Override columns available as custom columns on the claim Grid.
7			Not Available
8a	Patients Member ID	Patient > Member ID
8b	Patient Name	Patient > Name	Patient Last First MI (no extra punctuation)
9a	Patients Address	Patient > Address	Patient address (not insured)
9b	Patients City	Patient > City
9c	Patients State	Patient > State
9d	Patients Zip	Patient > Zip
9e			Not Available
10	Date of Birth	Patient > DOB
11	Sex	Patient > Sex	M, F, or U for Unknown
12	Admission Date	Claim > Admitted Date
13	Admission Hour	Claim > Admission Hour
14	Admission Type	Claim > Admission Type
15	Admission Source	Claim > Admission Source
16	Discharge Hour (DHR)	Claim > Discharge Hour
17	Patient Status (STAT)	Claim > Patient Status
18-21	Condition Codes	Claim Condition Code 1-4	Only 4 codes are available
22-28	Condition Codes		Not Available
29	Acdt State	Claim > Auto Accident State
30			Not Available
31a thru 34a	Occurrence Code Occurrence Date	Claim > Occurrence Code 1-4 Claim > Occurrence Date 1-4
31b thru 34b	Occurrence Code Occurrence Date	Claim > Occurrence Code 5-8 Claim > Occurrence Date 5-8
35a	Occurrence Span Code	Claim > Occurrence Span Code 1	Only 1 span is available
35a	Occurrence Span From-Through	Claim > Occurrence Span From 1 Claim > Occurrence Span To 1	Only 1 span is available
35b and 36a-b	Occurrence Span Code Occurrence Span From and Through Date		Not Available
38	Responsible Party Name and Address (Claim Addressee)	Claim > Bill To	Print the Bill To name and address. If the Bill To is Patient then the patient's address will print in this box.
39a-41a	Value Codes Amounts	Claim > Value Code 1-12 Claim > Value Code Amount 1-12	12 value codes/amounts available
39b-41d	Value Codes and Amounts		Not Available
42	Revenue Code	Claim > Revenue Code	Available on each service line. Will print blank if left blank. The Total charges line will automatically contain 0001.
43	Description	Claim > Service Line Description	Prints the service line description. Will print blank if left blank. No lookup is performed.
44	HCPCS/RATE/HIPPS CODE	Claim > Procedure	Will print procedure code with up to 4 modifiers. All separated by a space.
45	Service Date	Claim > Srvc Date	Lines sorted by revenue code then DOS
46	Service Units	Claim > Units
47	Total Charges	Claim > Charges	Will only be printed on the last page
48	Non Covered Charges	Claim > Non-Covered Charges	Available in EZClaim release 560 and higher
Line 23	Creation Date	Claim > Original Bill Date
Line 23	Total Charges		Calculated by EZClaim. Total of all Charges
Line 23	Total Non-Covered Charges		Non-Available
49			Not Available
50 A, B,C	Payer Name	Claim > Bill To	Up to 3 payers listed A – Primary B – Secondary C – Tertiary
51 A, B, C	Health Plan ID	Claim > Bill To	The Payer ID from the payer library A – Primary B – Secondary C – Tertiary
52	Release of Information	Patient > Patient Signature on File	Will print Y if Patient Signature on File is checked. Otherwise blank.
53	Assignment of Benefits	Patient > Insured Signature on File	Will print Y if the Insured Signature on File is checked. Otherwise blank.
54 A,B,C	Prior Payments		Will show as long as the claim Ignore Applied Amount is not checked
55 A,B,C	Est Amt Due from Payer		Not Available
56	NPI	Claim > Billing Provider	Provider NPI from the physician library
57	Other Provider ID	Claim > Billing Provider	Provider additional ID number (specific to payer). No qualifier is printed.
58	Insureds Name	Claim > Bill To > Name	Insured information
59	P. Rel	Claim > Bill To > Patient Rel to Insured	Insured information
60	Insureds Unique ID	Claim > Bill To > Insureds ID #	Insured
61	Group Name	Claim > Bill To > Insureds ID #
62	Insurance Group No	Claim > Bill To > Group #
63	Treatment Authorization Codes	Claim > Prior Auth #
64	Document Control Number	Claim > Original Ref Number	Original Ref Number from the claim screen. Will print in line A for a primary claim, line B for a secondary claim, and line C for a tertiary claim.
66	Diagnosis and Procedure Code Qualifier (ICD Version Indicator)	Claim > ICD Indicator	9 for ICD-9 or 0 for ICD-10
67	DX: principal diagnosis code	Claim Diagnosis A1	Diag A1
67 A-Q	Other diagnosis codes and Present On Admission (POA) indicator	Claim Diagnosis B2-L12	Diag B2-L12
69	ADMIT DX	Claim > Admitting Diagnosis
70 a, b, c	Patient Reason DX	Claim > Patient Reason 1,2,3
71	PPS	Claim > PPS Code
72	External Cause Code - ECI		Not available
73			Not Available
74	Principal Procedure Code and Date	Claim > Principal Procedure Code and Date
74a-e	Other Procedure Code and Date	Claim > Other Procedure Code and Date
75			Not Available
76 (NPI)	Attending Physician NPI	Claim > Attending	Provider NPI from the physician library
76 (QUAL and ID)	Attending Additional ID Numbers	Claim > Attending	Provider additional ID number from the physician library
76 (LAST and FIRST)	Attending Physician Last and First Name	Claim > Attending
77	Operating Phy	Claim > Operating Provider
78-79	Referring Phy and/or Rendering Phy	Claim > Referring Provider and/or Rendering Provider	Will populate box 78 if only one provider is selected or 78 and 79 if two providers are selected. Rendering providers will have a qualifier of 82 and referring providers will have a qualifier of DN. The rendering and referring provider will not print if their NPI is the same as the Attending.
80	Remarks	Claim > Remarks
81CC a	Code-Code Field	Claim > Billing Provider	Prints the billing provider's Taxonomy code. The prefix is B3 and the code is printed in the second column

Special Note on the POA indicator: The POA (Present on Admission) Indicator is a 25-character text value for potentially assigning POA indicators to each of the 25 diagnosis codes.

The first character in the string will be the POA indicator for the first diagnosis, the second character, for the second diagnosis, and so on.

To prevent any issues with leading or trailing spaces in EZClaim, users can use a special character (such as *) to represent a blank space when they do not want to assign a POA indicator to the first diagnosis. For example, using "*Y" would result in a POA of Y for the second diagnosis while leaving the first diagnosis without a POA indicator.