UB 04 special instruction

Some providers who use the UB-92 form need to follow specific instructions for certain Form Locators. If you are a specialty provider, look for Special Instructions: and the appropriate icon for you:

AFC Adult Family Care Homes
ICF-MR Intermediate Care Facilities-Mental Retardation
NF Nursing Facilities
PDN Private Duty Nursing
 PNMI Private Non-Medical Institutions

Examples and Additional Help
The instructions for each required Form Locator or field within a Form Locator include an example of what the completed Form Locator or field should look like. In some Form Locators that have special instructions for specific providers, there are additional examples.

The instructions also give you important information and help.
Look for these icons:
ALERT:
TIP:

Additional Tips on Filing

Here’s other important information you need to know before you begin filling out your form:

In addition to the National UB-92 manual, in order to complete the UB-92 form, you must have current CPT (Current Procedural Terminology) of the American Medical Association, ICD-9 (International Classification of Diseases) Diagnostic Codes, or HCPCS (Healthcare Common Procedure Coding System) Codes maintained by the Centers for Medicare and Medicaid Services.

The required format for a birth date is MMDDYYYY. (Example: January 19, 1947 = 01191947)
The alternative date format for dates of service or signature dates is MMDDYY.
DHHS will process your claim if you use that format, but we recommend that you transition to the eight-digit Y2K-compliant format.

Whether you fill in your claim form by typing, computer, or handwriting, keep all information within the designated FL. Do not overlap information into other form locators. Handwritten claims must be legible.