All UB-04 FL 1–81 fields with full descriptions & search.
| FL # | Field Name | Description |
|---|---|---|
| 1 | Billing Provider Info | Facility name, address, city, state & ZIP. |
| 2 | Pay-To Provider Info | Address where payment should be sent (if different). |
| 3 | Patient Control Number | Patient account/claim tracking number. |
| 4 | Type of Bill | Facility type, bill classification & frequency code. |
| 5 | Federal Tax Number | Provider's EIN or SSN. |
| 6 | Statement Covers Period | "From" and "Through" dates for services. |
| 7 | Reserved | Not used. |
| 8 | Patient Name | Full legal patient name. |
| 9 | Mailing Address | Patient’s full mailing address. |
| 10 | Birthdate | Patient's date of birth. |
| 11 | Sex | Patient gender. |
| 12 | Admission Date | Date patient was admitted. |
| 13 | Admission Hour | Time of admission in 24-hour format. |
| 14 | Admission Type | Emergency, urgent, elective, newborn, etc. |
| 15 | Admission Source | Where patient came from (clinic, ER, transfer). |
| 16 | Discharge Hour | Time patient was discharged. |
| 17 | Patient Status | Final patient disposition (home, SNF, expired, etc.). |
| 18–28 | Condition Codes | Codes describing conditions affecting claim/payment. |
| 29 | Accident State | State where accident occurred. |
| 30 | Reserved | Not used. |
| 31–34 | Occurrence Codes | Significant events & dates (accidents, onset dates). |
| 35–36 | Occurrence Span Codes | Event time periods with "From–To" dates. |
| 37 | Internal Control Number | Payer claim control number (for resubmissions). |
| 38 | Responsible Party | Person financially responsible. |
| 39–41 | Value Codes | Monetary or numeric info tied to billing. |
| 42 | Revenue Code | Revenue/service department code. |
| 43 | Description | Description of service or revenue category. |
| 44 | HCPCS / Rate | HCPCS codes, modifiers, and service rate. |
| 45 | Service Date | Date each service occurred. |
| 46 | Units | Number of units or service count. |
| 47 | Total Charges | Total charges for that revenue line. |
| 48 | Noncovered Charges | Charges patient/payer is not responsible for. |
| 49 | Reserved | Not used. |
| 50 | Payer Name | Primary, secondary, tertiary payer names. |
| 51 | Health Plan ID | Payer-specific plan identification. |
| 52 | Release of Information | Indicates whether ROIs are on file. |
| 53 | Assignment of Benefits | Whether provider accepts benefit assignment. |
| 54 | Prior Payments | Payments already made by patient/other payer. |
| 55 | Estimated Amount Due | Amount still expected from payer. |
| 56 | National Provider Identifier (NPI) | Billing provider’s 10-digit NPI. |
| 57 | Other Provider Identifier | Legacy identifiers or payer-required IDs (taxonomy, Medicaid ID, etc.). |
| 58 | Insured’s Name | Name of the insured/policyholder. |
| 59 | Patient Relationship to Insured | Relationship codes: Self, Spouse, Child, Other. |
| 60 | Insured’s Unique ID | Subscriber ID number exactly as on the insurance card. |
| 61 | Group Name | Employer or group plan name tied to the insurance. |
| 62 | Group Number | Group policy/plan identification number. |
| 63 | Authorization Number | Prior authorization, referral, or pre-certification number. |
| 64 | Document Control Number | Original payer claim reference for resubmission or adjustments. |
| 65 | Employer Name | Employer of the patient or insured. |
| 66 | Diagnosis Version | Indicates ICD version used (ICD-10 = “0”). |
| 67 | Principal Diagnosis | Main diagnosis responsible for admission. |
| 67A–67Q | Other Diagnosis Codes | Additional diagnoses contributing to care. |
| 68 | Reserved | Not used. |
| 69 | Admitting Diagnosis | Diagnosis that justified hospital admission. |
| 70 | Patient Reason for Visit | Up to three codes describing reason for outpatient visit. |
| 71 | PPS Code | DRG or Prospective Payment System code when required. |
| 72 | External Cause of Injury Codes | Codes describing external cause of injury (E-Codes). |
| 73 | Reserved | Not used. |
| 74 | Principal Procedure Code & Date | Main procedure performed & corresponding date. |
| 74A–74E | Other Procedure Codes & Dates | Additional significant procedures & dates. |
| 75 | Reserved | Not used. |
| 76 | Attending Provider | Attending physician’s NPI, name, and ID qualifiers. |
| 77 | Operating Provider | Operating surgeon's NPI & identifiers. |
| 78–79 | Other Providers | Additional rendering, referring, or supervising providers. |
| 80 | Remarks | Additional claim remarks, clarification, or payer-required notes. |
| 81 | Code-to-Code (C2–C9) | Payer-specific data such as taxonomy codes, condition indicators, or clarifying codes. |