UB(04) Form Print Options for All Payers

UB 04 Options	Description
[FL1] Billing/Location address	Prints the service location in FL1 and the billing information in FL2 from one of the following: <none> Blank Phys Billing Name/Address Includes the phone number and the override of the name from the UB tab of the payer. Service Facility Name/Address The service location name and address, which is the same information that prints in box 32 of the HCFA form.
[FL2] Billing/Location address	Prints the service location in FL1 and the billing information in FL2 from one of the following: <none> Blank Phys Billing Name/Address Includes the phone number and the override of the name from the UB tab of the payer. Service Facility Name/Address The service location name and address, which is the same information that prints in box 32 of the HCFA form. Service Facility Name/Address if different from FL1 Prints the service facility information if the address (line 1, city, state, and zip) is different from the phys billing address; otherwise, the FL is left blank.
[FL3a] Patient Control Number	Prints the patient control number on the form.
[FL3b] Medical Record Number	Prints the medical record number on the form.
[FL4] 4 Digit Bill Type	Prints the bill type with four digits in FL4. For example, if the Bill Type is a three-digit number, say 831, then it appears as 0831 on the form.
[FL8a] Patient Name	Prints the patient's name from one of the following: <none> Blank Current Payer's insured's policy # Patient Name
[FL9e] Country Code	Prints the country code on the form.
[FL17] Populate Patient Discharge status from Encounter Maintenance	Prints the two-digit patient status code that describes the patient's discharge status in box 17 of the UB04 claim form from the Encounter Maintenance window based on one of the following scenarios: When you enable the FL17 claim print option and select a Discharge Status option on the Encounter Maintenance window, it prints the patient status code corresponding to the selected discharge status in box 17. When you do not enable the FL17 claim print option, it prints the patient status code based on the last digit of the Type of Bill (TOB) in box 17. When you re-bill the UB04 paper claim form with default re-submission codes as 6, 7, or 8, it prints 01 as the patient discharge status instead of 30 in box 17. By default, the FL17 claim print option is disabled.
[FL30] Delay Reason Code	Based on the payer's requirements, this option prints either the encounter's delay reason code or the payer's auto delay reason code in field locator 30. The Delay Reason Code field is on the Billing & Collections tab of the Encounter Maintenance window. The Auto Delay Reason Code field is in the Other sub-tab on the Practice tab of the Payer Master window.
[FL37] Unassigned UB Field	Based on the payer's requirements, this option prints either the encounter's delay reason code or the payer's auto delay reason code in field locator 37. The Delay Reason Code field is on the Billing & Collections tab of the Encounter Maintenance window. The Auto Delay Reason Code field is in the Other sub-tab on the Practice tab of the Payer Master window.
[FL38] Resp Party/Address	Displays the name and address of responsible party or payer from one of the following: Blank Payer name/address Displays the name and address of the payer. If the address fields are not populated on the Modify Payer Information window, then only the payer name displays. Resp party name/address Displays the name and address of the patient or guarantor. By default, FL38 displays the Resp party name/address value.
[FL42] Four-digit Claim Total Rev Code	Prints a four-digit claim total rev code.
[FL43] NDC qualifier (N4) and NDC/Basis of Measure/Drug Unit Count	Prints the NDC number in field FL43. Note: When you select this option, it overrides the selected option set in the UB sub-tab of Code Description field on the Practice tab of the Payers master file.
[FL46] Align Service Units	Inserts space before or after the value.
[FL47] Align Total Charges	Inserts space before or after the value.
[FL47] Suppress commas in amount	Suppresses commas in claims printed for the form type UB (FL47).
[FL 48] Align Non-Covered Charges	Inserts space before or after the value.
[FL50] Payer Name	Prints the payer name from one of the following: Blank Payer Alias Payer Alias - Upper Case Payer Name Payer Name - Upper Case
[FL51] Health Plan ID	Prints the Health Plan ID from one of the following: Blank FL51 Value
[FL52] Release of Information	Prints the release of information from one of the following: Blank HIPAA electronic claims code Yes/No Yes/No/Restricted
[FL55] Include adjustments for payers?	Include the adjustments in FL55 calculations.
[FL56] NPI	Prints the NPI (National Provider Identifier) on the form.
[FL57] Other Provider ID	Prints the other provider's ID from one of the following: Blank FL51 Value Other Prov ID Prov Taxonomy Note: Values for these options are pulled from the Payer master file.
[FL59] Patient's Relationship to Insured - Code Set	Prints the patient's relationship from one of the following: Blank HIPAA electronic claims code set (from Relationship code table) NSF paper claims code set
[FL59] Patient's Relationship to Insured - Exception Codes	Prints the patient's relationship from one of the following: Blank 01 = NSF paper claims value for Self 99 = EPM value for Self G8 = HIPAA electronic claims 'Other' value for Self 18 for Self 18 for Self or 01 for Spouse
[FL60] Use Policy Override if entered	Allows you to use Policy Override, if it is entered.
[FL63] Treatment Authorization Codes	Print the treatment authorization codes from one of the following: Blank Authorization Number Authorization Number - Upper Case Referral Number
[FL64] Document Control Number	Prints the document control number from one of the following: Blank Resubmission Reference Number
[FL66] Diagnosis Indicator (ICD Version)	Print the diagnosis codes that affects the treatment received from one of the following: 0 – ICD-10 9 – ICD-9 Blank
[FL69] Populate admitting diag code	On the Diagnosis Selection window, when the admitting diagnosis code: IS populated, the first diagnosis code listed on the Diagnosis Selection window is populated in this field. IS NOT populated on the window. This field is populated with the first diagnosis code entered in Charge Entry.
[FL76] Attending NPI	Prints the attending physician's NPI number on the form.
[FL76] Attending Qualifier	Prints the attending physician's qualifier on the form.
[FL76] Attending Provider ID	Prints the attending physician's ID on the form from one of the following: <Payer Mstr Attending Setting> Blank Configurable To configure this field, you can set up a set of conditional functions that control what appears in the Attending Provider ID field based on the following criteria: If contents of FL51 match (enter the text that must be matched), then enter in FL76 (enter text to appear if condition is met). You can enter up to five sets of conditions in the manner described above. If there is no match when you set the configurable conditions, select one of the following options: Blank <Payer Mstr Attending Setting> UPIN & <Payer Mstr Attending Setting> License Number & <Payer Mstr Attending Setting> Provider ID & <Payer Mstr Attending Setting> UPIN & <Payer Mstr Attending Setting>
[FL77] Operating NPI	Prints the operating physician's NPI number on the form.
[FL77] Operating Qualifier	Prints the operating physician's qualifier on the form.
[FL77] Operating Provider ID	Prints the operating physician's provider ID on the form from one of the following: <Payer Mstr Operating Setting> <Use Legacy Standards> Blank Rendering - License Number & <Payer Mstr Operating Setting> Rendering - Provider ID & <Payer Mstr Operating Setting> Rendering - UPIN & <Payer Mstr Operating Setting>
[FL78] Other NPI	Prints the physician's NPI number on the form.
[FL78] Other Qualifier	Prints the physician's qualifiers on the form.
[FL78] Other Provider ID	Prints the physician's provider ID on the form from one of the following: <Payer Mstr Other Provider Setting> <Use Legacy Standards> Blank Rendering - License Number & <Payer Mstr Other Provider Setting> Rendering - Provider ID & <Payer Mstr Other Provider Setting> Rendering - UPIN & <Payer Mstr Other Provider Setting>
[FL80] Display payer address or narrative	This option draws attention to the attachments. Prints one of the following remarks: Narrative Payer Address Payer Address (with Payer Alias)
[FL81] CC - Code Code	Prints the provider's taxonomy qualifier and corresponding taxonomy code from one of the following: Attending Provider Taxonomy Blank Group Taxonomy

UB 04 Options	Description
[FL1] Billing/Location address	Prints the service location in FL1 and the billing information in FL2 from one of the following: <none> Blank Phys Billing Name/Address Includes the phone number and the override of the name from the UB tab of the payer. Service Facility Name/Address The service location name and address, which is the same information that prints in box 32 of the HCFA form.
[FL2] Billing/Location address	Prints the service location in FL1 and the billing information in FL2 from one of the following: <none> Blank Phys Billing Name/Address Includes the phone number and the override of the name from the UB tab of the payer. Service Facility Name/Address The service location name and address, which is the same information that prints in box 32 of the HCFA form. Service Facility Name/Address if different from FL1 Prints the service facility information if the address (line 1, city, state, and zip) is different from the phys billing address; otherwise, the FL is left blank.
[FL3a] Patient Control Number	Prints the patient control number on the form.
[FL3b] Medical Record Number	Prints the medical record number on the form.
[FL4] 4 Digit Bill Type	Prints the bill type with four digits in FL4. For example, if the Bill Type is a three-digit number, say 831, then it appears as 0831 on the form.
[FL8a] Patient Name	Prints the patient's name from one of the following: <none> Blank Current Payer's insured's policy # Patient Name
[FL9e] Country Code	Prints the country code on the form.
[FL17] Populate Patient Discharge status from Encounter Maintenance	Prints the two-digit patient status code that describes the patient's discharge status in box 17 of the UB04 claim form from the Encounter Maintenance window based on one of the following scenarios: When you enable the FL17 claim print option and select a Discharge Status option on the Encounter Maintenance window, it prints the patient status code corresponding to the selected discharge status in box 17. When you do not enable the FL17 claim print option, it prints the patient status code based on the last digit of the Type of Bill (TOB) in box 17. When you re-bill the UB04 paper claim form with default re-submission codes as 6, 7, or 8, it prints 01 as the patient discharge status instead of 30 in box 17. By default, the FL17 claim print option is disabled.
[FL30] Delay Reason Code	Based on the payer's requirements, this option prints either the encounter's delay reason code or the payer's auto delay reason code in field locator 30. The Delay Reason Code field is on the Billing & Collections tab of the Encounter Maintenance window. The Auto Delay Reason Code field is in the Other sub-tab on the Practice tab of the Payer Master window.
[FL37] Unassigned UB Field	Based on the payer's requirements, this option prints either the encounter's delay reason code or the payer's auto delay reason code in field locator 37. The Delay Reason Code field is on the Billing & Collections tab of the Encounter Maintenance window. The Auto Delay Reason Code field is in the Other sub-tab on the Practice tab of the Payer Master window.
[FL38] Resp Party/Address	Displays the name and address of responsible party or payer from one of the following: Blank Payer name/address Displays the name and address of the payer. If the address fields are not populated on the Modify Payer Information window, then only the payer name displays. Resp party name/address Displays the name and address of the patient or guarantor. By default, FL38 displays the Resp party name/address value.
[FL42] Four-digit Claim Total Rev Code	Prints a four-digit claim total rev code.
[FL43] NDC qualifier (N4) and NDC/Basis of Measure/Drug Unit Count	Prints the NDC number in field FL43. Note: When you select this option, it overrides the selected option set in the UB sub-tab of Code Description field on the Practice tab of the Payers master file.
[FL46] Align Service Units	Inserts space before or after the value.
[FL47] Align Total Charges	Inserts space before or after the value.
[FL47] Suppress commas in amount	Suppresses commas in claims printed for the form type UB (FL47).
[FL 48] Align Non-Covered Charges	Inserts space before or after the value.
[FL50] Payer Name	Prints the payer name from one of the following: Blank Payer Alias Payer Alias - Upper Case Payer Name Payer Name - Upper Case
[FL51] Health Plan ID	Prints the Health Plan ID from one of the following: Blank FL51 Value
[FL52] Release of Information	Prints the release of information from one of the following: Blank HIPAA electronic claims code Yes/No Yes/No/Restricted
[FL55] Include adjustments for payers?	Include the adjustments in FL55 calculations.
[FL56] NPI	Prints the NPI (National Provider Identifier) on the form.
[FL57] Other Provider ID	Prints the other provider's ID from one of the following: Blank FL51 Value Other Prov ID Prov Taxonomy Note: Values for these options are pulled from the Payer master file.
[FL59] Patient's Relationship to Insured - Code Set	Prints the patient's relationship from one of the following: Blank HIPAA electronic claims code set (from Relationship code table) NSF paper claims code set
[FL59] Patient's Relationship to Insured - Exception Codes	Prints the patient's relationship from one of the following: Blank 01 = NSF paper claims value for Self 99 = EPM value for Self G8 = HIPAA electronic claims 'Other' value for Self 18 for Self 18 for Self or 01 for Spouse
[FL60] Use Policy Override if entered	Allows you to use Policy Override, if it is entered.
[FL63] Treatment Authorization Codes	Print the treatment authorization codes from one of the following: Blank Authorization Number Authorization Number - Upper Case Referral Number
[FL64] Document Control Number	Prints the document control number from one of the following: Blank Resubmission Reference Number
[FL66] Diagnosis Indicator (ICD Version)	Print the diagnosis codes that affects the treatment received from one of the following: 0 – ICD-10 9 – ICD-9 Blank
[FL69] Populate admitting diag code	On the Diagnosis Selection window, when the admitting diagnosis code: IS populated, the first diagnosis code listed on the Diagnosis Selection window is populated in this field. IS NOT populated on the window. This field is populated with the first diagnosis code entered in Charge Entry.
[FL76] Attending NPI	Prints the attending physician's NPI number on the form.
[FL76] Attending Qualifier	Prints the attending physician's qualifier on the form.
[FL76] Attending Provider ID	Prints the attending physician's ID on the form from one of the following: <Payer Mstr Attending Setting> Blank Configurable To configure this field, you can set up a set of conditional functions that control what appears in the Attending Provider ID field based on the following criteria: If contents of FL51 match (enter the text that must be matched), then enter in FL76 (enter text to appear if condition is met). You can enter up to five sets of conditions in the manner described above. If there is no match when you set the configurable conditions, select one of the following options: Blank <Payer Mstr Attending Setting> UPIN & <Payer Mstr Attending Setting> License Number & <Payer Mstr Attending Setting> Provider ID & <Payer Mstr Attending Setting> UPIN & <Payer Mstr Attending Setting>
[FL77] Operating NPI	Prints the operating physician's NPI number on the form.
[FL77] Operating Qualifier	Prints the operating physician's qualifier on the form.
[FL77] Operating Provider ID	Prints the operating physician's provider ID on the form from one of the following: <Payer Mstr Operating Setting> <Use Legacy Standards> Blank Rendering - License Number & <Payer Mstr Operating Setting> Rendering - Provider ID & <Payer Mstr Operating Setting> Rendering - UPIN & <Payer Mstr Operating Setting>
[FL78] Other NPI	Prints the physician's NPI number on the form.
[FL78] Other Qualifier	Prints the physician's qualifiers on the form.
[FL78] Other Provider ID	Prints the physician's provider ID on the form from one of the following: <Payer Mstr Other Provider Setting> <Use Legacy Standards> Blank Rendering - License Number & <Payer Mstr Other Provider Setting> Rendering - Provider ID & <Payer Mstr Other Provider Setting> Rendering - UPIN & <Payer Mstr Other Provider Setting>
[FL80] Display payer address or narrative	This option draws attention to the attachments. Prints one of the following remarks: Narrative Payer Address Payer Address (with Payer Alias)
[FL81] CC - Code Code	Prints the provider's taxonomy qualifier and corresponding taxonomy code from one of the following: Attending Provider Taxonomy Blank Group Taxonomy

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