UB-04 Claim Form
The standardized hospital billing form (also called CMS-1450) used by hospitals and other institutional providers to bill Medicare, Medicaid, and commercial insurers for facility services.
On hospital cost-and-quality pages, UB-04 Claim Form carries a specific technical meaning that often differs from how the term is used in clinical practice or general medical writing. The definition here is the CMS-file usage. On the LakeQuality value rubric, UB-04 Claim Form is one of the inputs (directly or indirectly) to the combined cost-and-quality grade. Understanding how the term is computed at CMS — what counts and what does not — is part of reading hospital pages defensibly.
Each hospital page on LakeQuality surfaces the specific UB-04 Claim Form value for that facility (when CMS reports one), so the general definition here translates into a concrete data point on the per-hospital pages you actually use.
How It Works
The UB-04 is the universal institutional claim form developed by the National Uniform Billing Committee (NUBC) and adopted by CMS as the CMS-1450. Introduced in 2007 to replace the UB-92, it contains 81 form locators capturing the full billing detail for a hospital admission or outpatient encounter. Key form locators include patient demographics (FL 8-17), type of bill (FL 4, a three-digit code defining facility type, bill classification, and frequency), statement dates (FL 6), revenue codes with descriptions, HCPCS/CPT codes, service dates, units, and charges (FL 42-49), principal and secondary ICD-10-CM diagnosis codes (FL 67, 67A-Q), principal and other ICD-10-PCS procedure codes (FL 74, 74a-e), patient reason for visit for outpatient claims, and admit/discharge/transfer codes that drive readmission and transfer payment logic. Hospitals submit UB-04 electronically using the HIPAA 837-I (institutional) transaction set. On the receiving side, the claim is adjudicated against the MS-DRG grouper for inpatient claims or the OPPS/APC grouper for outpatient claims, producing the Medicare or insurer payment. Revenue codes (FL 42) group charges into categories like 0110 (room and board, private), 0250 (pharmacy), 0300 (laboratory), 0450 (emergency department), and 0636 (drugs requiring detailed coding). Accuracy on the UB-04 directly drives payment: a missing MCC diagnosis shifts an admission to a lower MS-DRG and loses the hospital $10,000-$20,000, while a missing modifier on an outpatient claim can cause denial or underpayment. The UB-04 is also the data source for claims-based quality measurement programs including HRRP, HACRP, and Value-Based Purchasing.
Related Terms
- ICD-10 Code, The International Classification of Diseases, 10th Revision, code used to identify patient diagnoses on hospital claims, replacing ICD-9 in the U.S. on October 1, 2015.
- CPT Code, The Current Procedural Terminology code maintained by the American Medical Association, used to identify outpatient procedures, office visits, and services on claims.
- MS-DRG (Medicare Severity DRG), The severity-adjusted version of the DRG system used by Medicare since 2007, expanding groupings to capture complication and comorbidity burden and refine payment accuracy.
- Diagnosis Related Group (DRG), A classification system that groups hospital inpatient stays into categories based on diagnosis, procedures, and patient complexity, used by Medicare to determine how much a hospital gets paid.
- Case Mix Index (CMI), A measure of the average complexity and resource intensity of a hospital's Medicare patients, calculated as the average MS-DRG relative weight across discharges.
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About This Definition
This definition is part of the HospitalCostData Hospital Pricing Glossary, 47 terms explaining hospital costs, quality ratings, and healthcare billing. Written for patients, journalists, researchers, and healthcare professionals.