UB 04 – Data requirment – Important field

• Provider name (field 1)                   • Discharge hour (field 16)
• Type of bill (field 4)                        • Patient status (field 17)
• Federal Tax ID number (field 5)      • Revenue code (field 42)
• Statement covers period (field 6)    • Payer name (field 50)
• Patient name (field 8)                      • Health plan ID (field 51)
• Patient address (field 9)                  • Insured’s name (field 58)
• Patient birth date (field 10)              • Patient’s relationship (field 59)
• Patient sex (field 11)                       • Insured’s unique ID (field 60)
• Admission date (field 12)                • Principal diagnosis code and POA indicator (field 67)
• Admission hour (field 13)                • Other diagnosis codes (field 67A-Q)
• Type of admission (field 14)            • Admitting diagnosis (field 69)
• Source of admission (field 15)         • Attending NPI/QUAL/ID/Last/First (field 76)