UB-04 Highlights: Sample Claim
See Injectable Drugs - UB-04 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 | 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). |
| ❷ | 39 | This form locator is a required field for erythropoietin administered in outpatient facilities and dialysis centers. The number 68 signifies the erythropoietin drug. The number 21,000 refers to the total amount of erythropoietin administered and/or supplied relating to the billing period. This amount must be reported in whole units. |
| ❸ | 42 | Revenue codes accurately reflect the services rendered. |
| ❹ | 44 | CPT and HCPCS codes coincide with appropriate revenue codes. |
| ❺ | 45 | Each day of treatment is listed on a separate line, with the respective dates of service listed in form locator 45. |
| ❻ | 46 | Units correspond to the appropriate revenue codes for administration and for the injectable drugs. |
Notes: Form Locator 46: Refer to Service Units in Injectable Drugs - General Information for more information.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |