Question on UB-04 Claim Form Fields FL01 and FL02 Differences

by Thushara
(India )

Hi – My doubt is regarding the UB-04 institutional claim form Field Locator FL02 “PAY TO” field.

How is it different from Field Locator FL01 and do we have to use NPI details if “PAY TO” is different from the Billing Provider?

Could you please explain with an example for this. Kindly reply.

Thanks in Advance.

Here’s my attempt to explain the requirements and differences of UB-04 (CMS-1450) claim form Field Locators FL01 and FL02 based on the NUBC (National Uniform Billing Committee) manual:

From the NUBC manual I don’t see that the NPI number is required in the FL01 or FL02 fields. I think this goes in field FL56. I assume NPI is required in field FL76 regardless of whether the billing provider FL02 field is used.

Attending provider NPI goes in FL76 and operating provider in FL77. Any other providers NPI would go in FL78 and 79.

FL01 is billing provider name, address, and telephone number are entered. This must be the physical street address and not a P.O. Box where the services were performed. The name, address, and telephone number are required in this field. If services performed outside of the United States, the country code is also required.

The FL01 field should be completed as follows:

Line 1: Provider Name
Line 2: Physical Street Address
Line 3: City, State, ZIP Code
Line 4: Telephone Number

FL02 is the “Pay To” name and address which may be different than the information in FL01 fields. This is situational and required when the name and address the provider wants payment to be sent – IF DIFFERENT THAN FL01.

When the FL02 field is used, it should be completed as follows:

Line 1: Pay to Name
Line 2: Street address OR P. O. Box
Line 3: City, State, ZIP Code
Line 4: Not Used

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