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UB-04 Form At A Glance - Interactive

UB-04
The documentation for the UB-04 below is relevant to MacPractice versions 5.0+ only. See the link below to navigate to the interactive claim form. This claim form allows you to click in a specific claim field to find where the data needs to be entered in MacPractice.

 

UB Box 1 - Office Demographics
Information is populated from the office name and address fields found in the Office reference.

This information can only be changed or updated by MacPractice.

UB-Box-1.png

UB Box 2
MacPractice does not populate this information; it must be entered manually.

UB Box 3a - Pat CNTL
This information comes from the Patient ID that is automatically assigned to each patient in MacPractice.

UB-Box-3a.png

UB Box 3b - Med Rec #
This information comes from the Chart Number that is designated in the Patient tab in the Patient Ability.

U
B Box 4 - Type Of Bill
This box pulls from the Type of Bill field from the Office Reference.
UB-Box-4.png

UB Box 5 - Fed. Tax No
MacPractice does not populate this information; it must be entered manually.

UB Box 6 - Statement Covers Period
MacPractice does not populate this information; it must be entered manually.

UB Box 7
This box is intentionally blank and is a place holder for future use.

UB Box 8a - Subscriber Number
This box pulls from the Subscriber ID assigned to the patient'€™s insurance in the Patient Ability.
UB-Box-8a.png

UB Box 8b - Patient Name
This box pulls from the Patient Name fields in the Patient Ability.
UB-Box-8b.png

UB Box 9a - Patient Street Address
This box pulls from the Street Address and Suite/Apt. Number boxes in the Patient Ability.
UB-Box-9a.png

UB Box 9b - Patient City
This box pulls from the City box in the Patient Ability.
UB-Box-9b.png

UB Box 9c - Patient State
This box pulls from the State box in the Patient Ability.
UB-Box-9c.png

UB Box 9d - Patient Zip Code
This box pulls from the Zip Code box in the Patient Ability.
UB-Box-9d.png

UB Box 9e
MacPractice does not populate this information; it must be entered manually.

UB Box 10 - Birthdate
This box pulls from the Birth Date box in the Patient Ability.
UB-Box-10.png

UB Box 11 - Sex
This box pulls from the Sex box in the Patient Ability.
UB-Box-11.png

UB Box 12 - Admission Date
This box pulls from the Admitted Date in the Charge Window from the Ledger.
UB-Box-12.png
 
This box does not exist in DDS versions of MacPractice, so for this version it will need to be entered manually.

UB Box 13 - Admission HR
MacPractice does not populate this information; it must be entered manually.

UB Box 14 - Admission Type
MacPractice does not populate this information; it must be entered manually.

UB Box 15 - Admission Src
MacPractice does not populate this information; it must be entered manually.

UB Box 16 - DHR
MacPractice does not populate this information; it must be entered manually.

UB Box 17 - STAT
MacPractice does not populate this information; it must be entered manually.

UB Box 18-28 - Condition Codes
MacPractice does not populate this information; it must be entered manually.

UB Box 29 - ACDT State
MacPractice does not populate this information; it must be entered manually.

UB Box 30
MacPractice does not populate this information; it must be entered manually.

UB Box 31-34 - Occurrence Date
MacPractice does not populate this information; it must be entered manually.

UB Box 35-36 - Occurrence Span
MacPractice does not populate this information; it must be entered manually.

UB Box 37
MacPractice does not populate this information; it must be entered manually.

UB Box 38 - Patient Info
This box pulls from the Patient Name and Address/City/State/Zip Code information in the Patient Ability.
UB-Box-38.png

UB Box 39-41 - Value Codes Amount
MacPractice does not populate this information; it must be entered manually.

UB Box 42 - Rev. Cd.

This box pulls from the Revenue Code box in the Fee Schedule Reference. In MacPractice Builds 7.3 and prior, this box is located in the Fee tab as in the screenshot below.
In MacPractice Builds 9 and above, the Revenue Code box is located in the Specialty tab of the Fee Schedule reference.

7.3 and prior builds

UB-Box-42.png

Builds 9 and above

Screen_Shot_2018-07-19_at_11.31.52_AM.png

UB Box 43 - Description
Information in this box is pulled from the Procedure Description field in the charge window.

The procedure description is determined by the procedure code selected, which will pull from the Fee Schedule reference.

UB-Box-43.png

UB Box 44 - HCPCS/RATE/HIPPS Code
The box pulls from the Code and Modifiers in the charge window.
UB-Box-44.png

UB Box 45 - Service Date
The box pulls from the Procedure Date in the charge window.

UB Box 46 - Service Units
The box pulls from the Units designated in the charge window.
UB-Box-46.png

UB Box 47 - Total Charges
The box pulls from the Unit Fee and applicable Taxes that are designated in the charge window.
UB-Box-47.png

UB Box 48 - Non-Covered Charges
MacPractice does not populate this information; it must be entered manually.

UB Box 49
MacPractice does not populate this information; it must be entered manually.

UB Box 50 - Payer Name
The box pulls from the Insurance Companies designated in the Claim Creation window.
UB-Box-50.1.png

These companies are selected through the active insurance in the Patient Tab.
UB-Box-50.2.png

UB Box 51 - Health Plan ID
The information for this box comes from the Paper ID field in the Insurance Company reference for the provider on the claim.
UB-Box-51.png

UB Box 52 - Rel Info
This box is populated when the box for Release of Info is checked in the Primary/Secondary tabs.
UB-Box-52.png

UB Box 53 - ASG BEN
This box is populated when the box for Signature on File is checked in the Primary/Secondary tabs.
UB-Box-53.png

UB Box 54 - Prior Payments
MacPractice does not populate this information; it must be entered manually.

UB Box 55 - EST. Amount Due
MacPractice does not populate this information; it must be entered manually.

UB Box 56 - NPI
This box pulls from the National Provider ID in Claim Credentials tab inside the Provider tab of the User Reference.
UB-Box-56.png

UB Box 57 - Other Provider ID
MacPractice does not populate this information; it must be entered manually.

UB Box 58 - Insured's Name
This box pulls from the Name fields for Primary/Secondary in the Patient Ability.
UB-Box-58.png

UB Box 59 - Patient Relationship
This box pulls a two digit code relative to the patient's relationship to Primary/Secondary.
UB-Box-59.png

Codes for the patient's relationship to the insured
01 = Spouse
18 = Self
19= Child
20 = Employee
21 = Unknown
39 = Organ Donor
40 = Cadaver Donor
53 = Life Partner
G8 = Other Relationship

UB Box 60 - Insured's Unique ID
This box pulls from the Subscriber ID in the Patient's Insurance tab.
UB-Box-60.png

UB Box 61 - Group Name
This box pulls from Plan Name for the patient's enabled insurance.
UB-Box-61.1.png
 
The plan name is selected through the Primary/Secondary insurance information.
UB-Box-61.2.png

UB Box 62 - Insurance Group No.
The box populates the Group # designated in the Patient tab.
UB-Box-62.png

UB Box 63 - Treatment Authorization Codes
The box pulls from the Prior Authorization number in the Incident associated with the charge.
UB-Box-63.png

UB Box 64 - Document Control Number
MacPractice does not populate this information; it must be entered manually.

UB Box 65 - Employer Name
The box pulls the name of the employer (if any) designated to the Primary/Secondary.
UB-Box-65.png

UB Box 66 - Diagnosis/Procedure Code Qualifier
MacPractice does not populate this information; it must be entered manually.

UB Box 67 - Principal/Other Diagnosis Codes
This box pulls from the Diagnosis Codes from the new charge window.

UB-Box-67.png

UB Box 68 - Future Use
MacPractice does not populate this information; it must be entered manually.

UB Box 69 - Admitting Diagnosis Code
MacPractice does not populate this information; it must be entered manually.

UB Box 70 - Patient's Reason for Visit Code
MacPractice does not populate this information; it must be entered manually.

UB Box 71 - PPS Code
MacPractice does not populate this information; it must be entered manually.

UB Box 72 - External Cause of Injury Code
MacPractice does not populate this information; it must be entered manually.

UB Box 73 - Future Use
MacPractice does not populate this information; it must be entered manually.

UB Box 74 - Principal Procedure Code/Date
MacPractice does not populate this information; it must be entered manually.

UB Box 75 - Future Use
MacPractice does not populate this information; it must be entered manually.

UB Box 76 - Attending Name
This box pulls the Provider'€™s name and NPI number designated in the New Charge window.

UB-Box-76.png

UB Box 77 - Operating ID
This box pulls the Provider'€™s name and NPI number designated in the New Charge window.

UB Box 78 - Other ID
MacPractice does not populate this information; it must be entered manually.

UB Box 79 - Other ID
MacPractice does not populate this information; it must be entered manually.

UB Box 80 - Remarks
This box pulls from the Demographic tab associated with the Insurance Plan.
UB-Box-80.png
UB Box 81 - Code-Code Field/Qualifiers
MacPractice does not populate this information; it must be entered manually.
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    Sarah LaRose

    In 9.9 and 10, box 42 for the revenue code is under the specialty tab.