Which form is described as a single-page form containing 81 numbered items on the front and additional information on the back?

Which form is described as a single-page form containing 81 numbered items on the front and additional information on the back?

• A. CMS-1500
• B. Official UB-04 Data Specifications Manual
• C. Form Locator
• D. UB-04

Answer: (D)

UB-04 is the standard hospital/institution claim form. It’s designed as a single-page document with 81 numbered items on the front—the form locators—where you enter the essential data about the patient, encounter, provider, payer, and the diagnosis and procedure details. The back side holds additional fields for supplementary information that may be needed for processing the claim. This layout is specific to institutional billing, unlike the CMS-1500, which is used for professional services and has a different structure. The Official UB-04 Data Specifications Manual explains these fields and how to complete them, and a Form Locator is simply one of those data-item positions on the form, not the form itself.

UB-04 is the standard hospital/institution claim form. It’s designed as a single-page document with 81 numbered items on the front—the form locators—where you enter the essential data about the patient, encounter, provider, payer, and the diagnosis and procedure details. The back side holds additional fields for supplementary information that may be needed for processing the claim. This layout is specific to institutional billing, unlike the CMS-1500, which is used for professional services and has a different structure. The Official UB-04 Data Specifications Manual explains these fields and how to complete them, and a Form Locator is simply one of those data-item positions on the form, not the form itself.