UB-04 Form at a Glance

Owned by Dylan Nigh
Last updated: Oct 05, 2023
8 min read

This article covers all the fields in the UB-04 fields and how each box is populated 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 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 3b - Med Rec #

This information comes from the Chart Number that is designated in the Patient tab in the Patient Ability.

UB Box 4 - Type Of Bill

This box pulls from the Type of Bill field from the Office Reference.

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 8b - Patient Name

This box pulls from the Patient Name fields in the Patient Ability.

UB Box 9a - Patient Street Address

This box pulls from the Street Address and Suite/Apt. Number boxes in the Patient Ability.

UB Box 9b - Patient City

This box pulls from the City box in the Patient Ability.

UB Box 9c - Patient State

This box pulls from the State box in the Patient Ability.

UB Box 9d - Patient Zip Code

This box pulls from the Zip Code box in the Patient Ability.

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 11 - Sex

This box pulls from the Sex box in the Patient Ability.

UB Box 12 - Admission Date

This box pulls from the Admitted Date in the Charge Window from the Ledger.

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 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

Builds 9 and above

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 44 - HCPCS/RATE/HIPPS Code

The box pulls from the Code and Modifiers in the charge window.

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 47 - Total Charges

The box pulls from the Unit Fee and applicable Tax Rate and Tax Type Reference Nodes  that are designated in the charge window.

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.

These companies are selected through the active insurance in the Patient Tab.

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 52 - Rel Info

This box is populated when the box for Release of Info is checked in the Primary/Secondary tabs.

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 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 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 59 - Patient Relationship

This box pulls a two digit code relative to the patient's relationship to Primary/Secondary.

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 61 - Group Name

This box pulls from Plan Name for the patient's enabled insurance.

The plan name is selected through the Primary/Secondary insurance information.

UB Box 62 - Insurance Group No.

The box populates the Group # designated in the Patient tab.

UB Box 63 - Treatment Authorization Codes

The box pulls from the Prior Authorization number in the Incident associated with the charge.

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 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 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 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 81 - Code-Code Field/Qualifiers

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