UB-04 Highlights: Sample Claim
Click Chemotherapy - UB04 Highlights [PDF] to view a sample of the claim explained below.
Note: It may be helpful to print the sample claim, then return to this page.
Explanation of Sample Claim
| FORM IDENTIFIER | FORM LOCATOR | EXPLANATION |
|---|---|---|
| ❶ | 6 | "From" and "Through" correspond to the actual service dates (form locator 45). |
| ❷ | 4 | Type of bill 131 indicates the type of facility is a hospital (1), the bill classification is outpatient (3) and the frequency is admit through discharge (1). |
| ❸ | 42 | Revenue codes are appropriate for principal diagnosis code (form locator 66). |
| ❹ | 44 | HCPCS codes correspond to appropriate revenue codes. For example, Q0085 is paired with revenue code 335, while J codes are matched with revenue code 636 (drugs requiring specific identification). |
| ❺ | 45 | Separate lines are used for each day of therapy. |
| ❻ | 46 | Service units relate to appropriate HCPCS codes for the amount of chemotherapy drugs administered. Refer to Units in this section for more information. |
| ❼ | 51 | Use the correct HMSA assigned hospital outpatient services provider number. |
| ❽ | 67 | The principal diagnosis code (171.5) falls within the general range of chemotherapy-related diagnoses. |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |