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UB-04 Completion: Outpatient Services
Page updated: September 2020
The UB- 04 claim form is used to submit claims for outpatient services by institutional
facilities (for example, outpatient departments, Rural Health Clinics and chronic dialysis
centers). See UB-04 Completion: Inpatient Services in the Part 2 Inpatient Services Manual
for billing instructions for services rendered to a registered hospital inpatient.
If the patient is treated as an outpatient in a hospital different from the one in which the
patient is registered, the services must be billed by the treating hospital using the UB- 04
claim form with the appropriate facility type code (which is the first two digits in the Type of
Bill field [Box 4]) for the outpatient facility.
Most claims for outpatient services can also be submitted through Computer Media Claims
(CMC). For CMC ordering and enrollment information, refer to the CMC section in the Part 1
manual.
For additional billing information, refer to the UB-04 Special Billing Instructions for Outpatient
Services, UB-04 Submission and Timeliness Instructions and UB- 04 Tips for Billing:
Outpatient Services sections in this manual.
LEA Providers:
Timeliness limitations differ for Local Educational Agency (LEA) providers. LEA providers
refer to the Local Educational Agency (LEA) Billing and Reimbursement Overview section.
For crossover billing information, refer to the Medicare/Medi-Cal Crossover Claims:
Outpatient Services and Medicare/Medi-Cal Crossover Claims: Outpatient Services Billing
Examples.
Medi-Cal cannot process credits or adjustments on the UB- 04 form. Refer to the CIF
Completion and CIF Special Billing Instructions for Outpatient Services sections in the
appropriate Part 2 manual for information about claim adjustments.
Page updated: September 2020
Figure 1: Medi-Cal Required Fields for Outpatient UB- 04 Claims
Page updated: October 2021
Table of Facility Type Codes
Code Facility Type
Hospital, Outpatient
Hospital, Laboratory Services Provided to Non-Patients
Skilled Nursing, Outpatient
Home Health Services Under a Plan of Treatment
Home Health Services, Not Under a Plan of Treatment
43 Religious Non-Medical Health Care Institutions, Outpatient Services
Clinic, Rural
Clinic, Hospital Based or Independent Renal Dialysis Center
Clinic, Freestanding
Clinic, Outpatient Rehabilitation Facility (ORF)
Clinic, Comprehensive Outpatient Rehabilitation Facility (CORF)
Clinic, Community Mental Health Center
77 Federally Qualified Health Center (FQHC)
78 Licensed Freestanding Emergency Medical Facility
Clinic, Other
Specialty Facility, Hospice (non-hospital based)
Specialty Facility, Hospice (hospital based)
Specialty Facility, Ambulatory Surgery Center
Specialty Facility, Freestanding Birthing Center
85 ‹‹Specialty Facility, Critical Access Hospital››
87 Specialty Facility, Freestanding Non-Residential Opioid Treatment Program
Specialty Facility, Other
Notes: Only one facility type may be billed on each claim. Outpatient services not logically
compatible with the facility type identified on the claim must be billed on a separate
claim.
For subacute services, specify the appropriate Place of Service and use modifier U2.
Page updated: October 2021
Table of Form Items Descriptions (Continued)
Item Description
- Type of bill (continued). Clinics and outpatient hospitals use one of the following
codes as the first two digits of the three-character type of bill code:
Table of Facility Type Codes by Provider Type
Provider Type Facility Type
AIDS Waiver Agency ‹‹ 13, 32, 34 79
Chronic Dialysis Clinic 72
Community Hospital, Outpatient 13
Community Mental Health Clinic 76
Employer/Employee Clinic 79
Exempt from Licensure Clinic 79
Free Clinic 79
Home Health Agency ‹‹ 32, 34
Local Educational Agency 89
Multispecialty Clinic 79
Rehab Clinic 74
Rehab Clinic (Comprehensive) 75
Rural Health Clinic 71
Surgical Clinic 73, 79
Page updated: October 2021
Organ Donors
When submitting a claim for a patient donating an organ to a Medi-Cal recipient, enter the
donor’s name, date of birth and sex in the appropriate boxes. Enter the Medi-Cal recipient’s
name in Box 58 ( Insured’s Name ) and enter “11” (donor) in Box 59 ( Patient’s Relationship to
Insured).
Table of Form Items Descriptions (Continued)
Item Description
9A thru
E
Patient address. Not required by Medi-Cal.
- Birthdate. Enter the patient’s date of birth in an eight-digit MMDDYYYY (Month,
Day, Year) format (for example, September 16, 1967 = 09161967). If the
recipient’s full date of birth is not available, enter the year preceded by 0101.
(For newborns and organ donors, see Item 8B.)
Page updated: October 2021
Table of Form Items Descriptions (Continued)
Item Description
- Sex. Use the capital letter “M” for male, or “F” for female. (For newborns and
organ donors, see Item 8B on a previous page.)
- Admission date. Not required by Medi-Cal.
- Admission hour. Not required by Medi-Cal.
- Admission type. ‹‹Not required by Medi-Cal.››
- Admission source. Not required by Medi-Cal.
- Discharge hour. Not required by Medi-Cal.
- Status. Not required by Medi-Cal.
18 thru
Condition codes. Condition codes are used to identify conditions relating to
this claim that may affect payer processing.
Although the Medi-Cal claims processing system only recognizes the condition
codes on the following pages, providers may include codes accepted by other
payers. The claims processing system ignores all codes not applicable to
Medi-Cal.
Condition codes should be entered from left to right in numeric-alpha sequence
starting with the lowest value. For example, if billing for three condition codes,
“A1”, “80” and “82”, enter “80” in Box 18, “82” in Box 19 and “A1” in Box 20.
Applicable Medi-Cal codes are:
Other Coverage: Enter code “80” if recipient has Other Health Coverage
(OHC). OHC includes insurance carriers as well as Prepaid Health Plans
(PHPs) and Health Maintenance Organizations (HMOs) that provide any of the
recipient’s health care needs. Eligibility under Medicare or a Medi-Cal
managed care plan is not considered other coverage and is identified
separately.
Medi-Cal policy requires that, with certain exceptions, providers must bill the
recipient’s other health insurance prior to billing Medi-Cal. (For details about
OHC, refer to the Other Health Coverage (OHC) Guidelines for Billing section
in the Part 1 manual.)
Page updated: September 2020
Table of Form Items Descriptions (Continued)
Item Description
18 thru
Condition codes (continued). Medicare Status: Medicare status codes are
required for Charpentier claims. In all other circumstances, these codes are
optional; therefore, providers may leave this area of the Condition Codes fields
(Boxes 18 thru 24) blank. The Medicare status codes are:
‹‹Table of Medicare Status Codes and Descriptions››
Code Description
Y0 Under 65, does not have Medicare coverage
Y
Y
- Utilization committee denial or physician non-certification
Y
Y
Y
Y
Y
- Medicare benefits denied or cut short by Medicare intermediary
Y8 Non-covered services
Y 9
Z
- Medi/Medi Charpentier: Benefit Limitations
Z
- Medi/Medi Charpentier: Rates Limitations
Z
- Medi/Medi Charpentier: Both Rates and Benefit Limitations
Table of Form Items Descriptions (Continued)
Item Description
25 thru
Condition codes. The Medi-Cal claims processing system only recognizes
condition codes entered in Boxes 18 thru 24.
- Acdt state. Not required by Medi-Cal.
- Unlabeled. Not required by Medi-Cal.
Page updated: September 2020
Table of Form Items Descriptions (Continued)
Item Description
31 thru
34A thru
B.
Occurrence codes and dates. Occurrence codes and dates are used to
identify significant events relating to a claim that may affect payer processing.
Occurrence codes and dates should be entered from left to right, top to bottom
in numeric-alpha sequence starting with the lowest value. For example, if billing
for two occurrence codes “24” (accepted by another payer) and ”05”
(accident/no medical or liability coverage), enter “05” in Box 31A and “24” in
Box 32A. Refer to Figure 2 below.
Figure 2. Occurrence Codes Example.
Table of Form Items Descriptions (Continued)
Item Description
31 thru
34A thru
B.
Occurrence codes and dates. (continued). Although the Medi-Cal claims
processing system will only recognize the following codes, providers may
include codes and dates billed to other payers in Boxes 31 thru 34. The claims
processing system will ignore all codes not applicable to Medi-Cal.
Applicable Medi-Cal codes are:
Enter code “04” (accident/employment-related) in Boxes 31 through 34 if the
accident or injury was employment related. Enter one of the following codes if
the accident or injury was non-employment related:
Table of Occurrence Codes and Descriptions
Code Description
01 Accident/medical coverage
02 No fault insurance involved – including auto accident/other
03 Accident/tort liability
05 Accident/no medical or liability coverage
06 Crime victim
In six-digit MMDDYY (Month, Day, Year) format, enter the date of accident/injury in the
corresponding box.
Page updated: September 2020
Table of Form Items Descriptions (Continued)
Item Description
39 thru
41A thru
D.
Value codes and amount. Patient’s Share of Cost. Value codes and
amounts should be entered from left to right, top to bottom in numeric-alpha
sequence, starting with the lowest value. For example, if billing for two value
codes “30” (accepted by another payer) and “23” (accepted by Medi-Cal), enter
“23” in Box 39A and “30” in Box 40A. ( See Figure 3 below.)
Value codes and amounts are used to relate amounts to data elements
necessary to process the claim. Although the Medi-Cal claims processing
system only recognizes code “23,” providers may include codes and dates
billed to other payers in Boxes 39 thru 41. The claims processing system will
ignore all codes not applicable to Medi-Cal.
Enter code “23” and the amount of the patient’s Share of Cost for the
procedure or service, if applicable. Do not enter a decimal point (.), dollar sign
($), positive (+) or negative (-) sign. Enter full dollar amount and cents, even if
the amount is even (for example, if billing for $100, enter 10000 not 100). For
more information about Share of Cost, see the Share of Cost: UB-04 for
Outpatient Services section in this manual.
Figure 3: Value Codes Example.
Page updated: September 2020
Table of Form Items Descriptions (Continued)
Item Description
39 thru
41A thru
D.
Value codes and amount. Patient’s Share of Cost (continued).
- Revenue code. Revenue codes are required (for instance, for organ
procurement) for select outpatient billing. Specific instructions are included in
select provider manual sections.
Total Charges: Enter “001” on line 23, and enter the total amount on line 23,
field 47.
- Description. This field will help you separate and identify the descriptions of
each service. The description must identify the particular service code
indicated in the HCPCS/Rate/HIPPS Code field (Box 44). For more
information, refer to the CPT
®
code book. This field is optional except when
billing for physician-administered drugs.
Entering the National Drug Code (NDC) for Physician-Administered
Drugs : Enter the product ID qualifier N4 followed by the 11-digit NDC (no
spaces or hyphens). Directly following the last digit of the NDC (no space),
enter the two-character unit of measure qualifier followed by the numeric
quantity. Refer to the Physician-Administered Drugs – NDC: UB-04 Billing
Instructions section in this manual for more information.
Notes : Unit of measure and numeric quantity are optional. Absence of these
two elements will not result in claim denial.
If there are multiple pages of the claim, enter the page numbers on line 23 in
this field.
Page updated: September 2020
Table of Form Items Descriptions (Continued)
Item Description
- Service date. Enter the date the service was rendered in six-digit, MMDDYY
(Month, Day, Year) format, for example, June 24, 20 20 = 062420.
‘From-Through’ Billing
For “From-Through” billing instructions, refer to the UB-04 Special Billing Instructions for
Outpatient Services section in this manual.
‹‹Table of Form Items Descriptions (Continued)››
Item Description
- Service units. Enter the actual number of times a single procedure or item was
provided for the date of service. Medi-Cal only allows two digits in this field. If
billing for more than 99, divide the units on two or more lines.
- Total charges. In full dollar amount, enter the usual and customary fee for the
service billed. Do not enter a decimal point (.) or dollar sign ($). Enter full dollar
amount and cents, even if the amount is even (for example, if billing for $100,
enter 10000 not 100). If an item is a taxable medical supply, include the
applicable state and county sales tax.
Note : Medi-Cal cannot process credits or adjustments on the UB- 04 form.
Refer to the CIF Completion and CIF Special Billing Instructions for
Outpatient Services sections in the appropriate Part 2 manual for
information regarding claim adjustments.
Enter the “Total Charge” for all services on line 23. Enter code 001 in Revenue
Code field (Box 42) to indicate that this is the total charge line (refer to Item 42
on a preceding page).
- Non-covered charges. Not required by Medi-Cal.
- Unlabeled. Not required by Medi-Cal.
Note : Providers may enter up to 22 lines of detail data (Items 42 thru 49). It is
also acceptable to skip lines.
To delete a line, mark through the boxes as shown in Figure 5. Be sure to draw
a thin line through the entire detail line using a blue or black ballpoint pen.
Figure 5: Line Deletion Example for UB- 04 Claim.
Page updated: September 2020
Table of Form Items Descriptions (Continued)
Item Description
50A thru
C.
Payer name. Enter “O/P MEDI-CAL” to indicate the type of claim and payer.
Use capital letters only. Refer to Figure 6.
When completing Boxes 50 thru 65 (excluding Box 56) enter all information
related to the payer on the same line (for example, Line A, B or C) in order of
payment (Line A: other insurance, Line B: Medicare, Line C: Medi-Cal). Do not
enter information on Lines A and B for other insurance or Medicare if payment
was denied by these carriers.
When billing other insurance, the other insurance is entered on Line A of
Box 50, with the amount paid by Other Coverage on Line A of Box 54 ( Prior
Payments ). All information related to the Medi-Cal billing is entered on Line B
of these boxes. Be sure to enter the corresponding prior payments on the
correct line.
If Medi-Cal is the only payer billed, all information in Boxes 50 thru 65
(excluding Box 56) should be entered on Line A.
Reminder : If the recipient has Other Health Coverage, the insurance carrier
must be billed prior to billing Medi-Cal.
Figure 6: Payer Name Example for UB- 04 Claim.
Page updated: September 2020
Table of Form Items Descriptions (Continued)
Item Description
- NPI. Enter the National Provider Identifier (NPI).
57A thru
C.
Other (billing) provider ID (Used by atypical providers only). Enter the
Medi-Cal provider number, corresponding to information on lines A, B or C.
Note : Required prior to the mandated NPI implementation date when an
additional identification number is necessary to identify the provider, or
if on and after the mandated NPI implementation, the NPI is not used in
Box 56 and an identification number other than the NPI is necessary
for the receiver to identify the provider.
58A thru
C.
Insured’s name. If billing for an infant using the mother’s ID or for an organ
donor, enter the Medi-Cal recipient’s name here and the patient’s relationship
to the Medi-Cal recipient in Box 59 ( Patient’s Relationship to Insured ). See
Item 8B on a previous page. This box is not required by Medi-Cal except
under the two circumstances listed in Item 8B.
59A thru
C.
Patient’s relationship to insured. If billing for an infant using the mother’s ID
or for an organ donor, enter the code indicating the patient’s relationship to
the Medi-Cal recipient (for example, “03” [child] or “11” [donor]). See Item 8B
on a previous page. This box is not required by Medi-Cal except under the
two circumstances listed in Item 8B.
60A thru
C.
Insured’s unique ID. Enter the 14-character recipient ID number as it
appears on the Benefits Identification Card (BIC) or paper Medi-Cal ID card.
Note : Medi-Cal does not accept Medicare ID Numbers.
Page updated: September 2020
Newborn Infant
When submitting a claim for a newborn infant for the month of birth or the following month,
enter the mother’s ID number in this field. (For more information, see Item 8B on a previous
page.)
Table of Form Items Descriptions (Continued)
Item Description
61A thru
C.
Group name. Not required by Medi-Cal.
62A thru
C.
Insurance group number. Not required by Medi-Cal.
63A thru
C.
Treatment authorization codes. For services requiring a Treatment
Authorization Request (TAR), enter the 11-digit TAR Control Number. It is not
necessary to attach a copy of the TAR to the claim. Recipient information on
the claim must match the TAR. Multiple claims must be submitted for services
that have more than one TAR. Only one TAR Control Number can cover the
services billed on any one claim.
Note : TAR and non-TAR procedures should not be combined on the same
claim.
