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Make sense of any

UB-04 Claim

Generate accurate and consistent data from any document, any layout.

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Healthcare Document Intelligence

The world's best UB-04 extraction

Accelerate institutional claim processing with automated UB-04 form extraction. Extract all 81 form locators including patient data, revenue codes, HCPCS/CPT codes, ICD-10 diagnosis and procedure codes, and occurrence codes. Reduce denials and speed up reimbursement.

ub-04.pdf

Viewer

JSON

form_locator_1_provider_name

Memorial General Hospital

form_locator_1_provider_address

1000 Hospital Drive, Chicago, IL 60601

form_locator_2_pay_to_name

Memorial General Hospital

form_locator_3a_patient_control_number

PAT-2024-123456

form_locator_3b_medical_record_number

MRN-2024-789012

form_locator_4_type_of_bill

0111

form_locator_5_federal_tax_number

36-1234567

form_locator_6_statement_period

from: 2024-03-10, through: 2024-03-12

form_locator_8_patient_name

Patricia A. Morgan

form_locator_9_patient_address

456 Oak Street, Chicago, IL 60602

form_locator_10_patient_dob

1955-07-22

form_locator_11_patient_sex

Female

form_locator_12_admission_date

2024-03-10

form_locator_13_admission_hour

14:00

form_locator_14_admission_type

1

form_locator_15_admission_source

7

form_locator_17_patient_status

01

form_locator_18_condition_codes

02, 04

Form_locator_31_occurrence_codes

1 item

code

date

11

2024-03-10

Form_locator_39_value_codes

1 item

code

amount

01

1,500

Form_locator_42_revenue_codes

5 items

line

revenue_code

description

hcpcs

service_date

units

total_charges

1

0120

Room & Board Semi-Private

2024-03-10

2

2,400

2

0250

Pharmacy

2024-03-10

1

850

3

0300

Laboratory

85025

2024-03-10

1

125

4

0320

Radiology-Diagnostic

71046

2024-03-11

1

350

5

0450

Emergency Room

99284

2024-03-10

1

1,200

form_locator_47_total_charges

4925

form_locator_50_payer_name

Blue Cross Blue Shield of Illinois

form_locator_51_health_plan_id

BCBSIL

form_locator_58_insured_name

Patricia A. Morgan

form_locator_60_insured_certificate_number

XYZ987654321

form_locator_63_treatment_authorization_codes

AUTH-2024-5678

form_locator_66_diagnosis_version

0

form_locator_67_principal_diagnosis

code: I21.3, description: ST elevation myocardial infarction of unspecified site, poa: Y

Form_locator_67a_other_diagnoses

3 items

code

description

poa

I10

Essential hypertension

Y

E11.9

Type 2 diabetes mellitus

Y

E78.5

Hyperlipidemia

Y

form_locator_74_principal_procedure

code: 02703ZZ, description: Dilation of coronary artery, percutaneous approach, date: 2024-03-11

form_locator_76_attending_physician

npi: 1234567890, name: Dr. William Zhang, MD

form_locator_77_operating_physician

npi: 0987654321, name: Dr. Lisa Huang, MD

form_locator_81_code_code

PR-1234567890

{ "form_locator_1_provider_name": "Memorial General Hospital", "form_locator_1_provider_address": "1000 Hospital Drive, Chicago, IL 60601", "form_locator_2_pay_to_name": "Memorial General Hospital", "form_locator_3a_patient_control_number": "PAT-2024-123456", "form_locator_3b_medical_record_number": "MRN-2024-789012", "form_locator_4_type_of_bill": "0111", "form_locator_5_federal_tax_number": "36-1234567", "form_locator_6_statement_period": { "from": "2024-03-10", "through": "2024-03-12"}, "form_locator_8_patient_name": "Patricia A. Morgan", "form_locator_9_patient_address": "456 Oak Street, Chicago, IL 60602", "form_locator_10_patient_dob": "1955-07-22", "form_locator_11_patient_sex": "Female", "form_locator_12_admission_date": "2024-03-10", "form_locator_13_admission_hour": "14:00", "form_locator_14_admission_type": "1", "form_locator_15_admission_source": "7", "form_locator_17_patient_status": "01", "form_locator_18_condition_codes": [ "02", "04"], "form_locator_31_occurrence_codes": [ { "code": "11", "date": "2024-03-10"} ], "form_locator_39_value_codes": [ { "code": "01", "amount": 1500 } ], "form_locator_42_revenue_codes": [ { "line": 1, "revenue_code": "0120", "description": "Room & Board Semi-Private", "hcpcs": null, "service_date": "2024-03-10", "units": 2, "total_charges": 2400 }, { "line": 2, "revenue_code": "0250", "description": "Pharmacy", "hcpcs": null, "service_date": "2024-03-10", "units": 1, "total_charges": 850 }, { "line": 3, "revenue_code": "0300", "description": "Laboratory", "hcpcs": "85025", "service_date": "2024-03-10", "units": 1, "total_charges": 125 }, { "line": 4, "revenue_code": "0320", "description": "Radiology-Diagnostic", "hcpcs": "71046", "service_date": "2024-03-11", "units": 1, "total_charges": 350 }, { "line": 5, "revenue_code": "0450", "description": "Emergency Room", "hcpcs": "99284", "service_date": "2024-03-10", "units": 1, "total_charges": 1200 } ], "form_locator_47_total_charges": 4925, "form_locator_50_payer_name": "Blue Cross Blue Shield of Illinois", "form_locator_51_health_plan_id": "BCBSIL", "form_locator_58_insured_name": "Patricia A. Morgan", "form_locator_60_insured_certificate_number": "XYZ987654321", "form_locator_63_treatment_authorization_codes": "AUTH-2024-5678", "form_locator_66_diagnosis_version": "0", "form_locator_67_principal_diagnosis": { "code": "I21.3", "description": "ST elevation myocardial infarction of unspecified site", "poa": "Y"}, "form_locator_67a_other_diagnoses": [ { "code": "I10", "description": "Essential hypertension", "poa": "Y"}, { "code": "E11.9", "description": "Type 2 diabetes mellitus", "poa": "Y"}, { "code": "E78.5", "description": "Hyperlipidemia", "poa": "Y"} ], "form_locator_74_principal_procedure": { "code": "02703ZZ", "description": "Dilation of coronary artery, percutaneous approach", "date": "2024-03-11"}, "form_locator_76_attending_physician": { "npi": "1234567890", "name": "Dr. William Zhang, MD"}, "form_locator_77_operating_physician": { "npi": "0987654321", "name": "Dr. Lisa Huang, MD"}, "form_locator_81_code_code": "PR-1234567890"}

ub-04.pdf

Viewer

JSON

form_locator_1_provider_name

Memorial General Hospital

form_locator_1_provider_address

1000 Hospital Drive, Chicago, IL 60601

form_locator_2_pay_to_name

Memorial General Hospital

form_locator_3a_patient_control_number

PAT-2024-123456

form_locator_3b_medical_record_number

MRN-2024-789012

form_locator_4_type_of_bill

0111

form_locator_5_federal_tax_number

36-1234567

form_locator_6_statement_period

from: 2024-03-10, through: 2024-03-12

form_locator_8_patient_name

Patricia A. Morgan

form_locator_9_patient_address

456 Oak Street, Chicago, IL 60602

form_locator_10_patient_dob

1955-07-22

form_locator_11_patient_sex

Female

form_locator_12_admission_date

2024-03-10

form_locator_13_admission_hour

14:00

form_locator_14_admission_type

1

form_locator_15_admission_source

7

form_locator_17_patient_status

01

form_locator_18_condition_codes

02, 04

Form_locator_31_occurrence_codes

1 item

code

date

11

2024-03-10

Form_locator_39_value_codes

1 item

code

amount

01

1,500

Form_locator_42_revenue_codes

5 items

line

revenue_code

description

hcpcs

service_date

units

total_charges

1

0120

Room & Board Semi-Private

2024-03-10

2

2,400

2

0250

Pharmacy

2024-03-10

1

850

3

0300

Laboratory

85025

2024-03-10

1

125

4

0320

Radiology-Diagnostic

71046

2024-03-11

1

350

5

0450

Emergency Room

99284

2024-03-10

1

1,200

form_locator_47_total_charges

4925

form_locator_50_payer_name

Blue Cross Blue Shield of Illinois

form_locator_51_health_plan_id

BCBSIL

form_locator_58_insured_name

Patricia A. Morgan

form_locator_60_insured_certificate_number

XYZ987654321

form_locator_63_treatment_authorization_codes

AUTH-2024-5678

form_locator_66_diagnosis_version

0

form_locator_67_principal_diagnosis

code: I21.3, description: ST elevation myocardial infarction of unspecified site, poa: Y

Form_locator_67a_other_diagnoses

3 items

code

description

poa

I10

Essential hypertension

Y

E11.9

Type 2 diabetes mellitus

Y

E78.5

Hyperlipidemia

Y

form_locator_74_principal_procedure

code: 02703ZZ, description: Dilation of coronary artery, percutaneous approach, date: 2024-03-11

form_locator_76_attending_physician

npi: 1234567890, name: Dr. William Zhang, MD

form_locator_77_operating_physician

npi: 0987654321, name: Dr. Lisa Huang, MD

form_locator_81_code_code

PR-1234567890

{ "form_locator_1_provider_name": "Memorial General Hospital", "form_locator_1_provider_address": "1000 Hospital Drive, Chicago, IL 60601", "form_locator_2_pay_to_name": "Memorial General Hospital", "form_locator_3a_patient_control_number": "PAT-2024-123456", "form_locator_3b_medical_record_number": "MRN-2024-789012", "form_locator_4_type_of_bill": "0111", "form_locator_5_federal_tax_number": "36-1234567", "form_locator_6_statement_period": { "from": "2024-03-10", "through": "2024-03-12"}, "form_locator_8_patient_name": "Patricia A. Morgan", "form_locator_9_patient_address": "456 Oak Street, Chicago, IL 60602", "form_locator_10_patient_dob": "1955-07-22", "form_locator_11_patient_sex": "Female", "form_locator_12_admission_date": "2024-03-10", "form_locator_13_admission_hour": "14:00", "form_locator_14_admission_type": "1", "form_locator_15_admission_source": "7", "form_locator_17_patient_status": "01", "form_locator_18_condition_codes": [ "02", "04"], "form_locator_31_occurrence_codes": [ { "code": "11", "date": "2024-03-10"} ], "form_locator_39_value_codes": [ { "code": "01", "amount": 1500 } ], "form_locator_42_revenue_codes": [ { "line": 1, "revenue_code": "0120", "description": "Room & Board Semi-Private", "hcpcs": null, "service_date": "2024-03-10", "units": 2, "total_charges": 2400 }, { "line": 2, "revenue_code": "0250", "description": "Pharmacy", "hcpcs": null, "service_date": "2024-03-10", "units": 1, "total_charges": 850 }, { "line": 3, "revenue_code": "0300", "description": "Laboratory", "hcpcs": "85025", "service_date": "2024-03-10", "units": 1, "total_charges": 125 }, { "line": 4, "revenue_code": "0320", "description": "Radiology-Diagnostic", "hcpcs": "71046", "service_date": "2024-03-11", "units": 1, "total_charges": 350 }, { "line": 5, "revenue_code": "0450", "description": "Emergency Room", "hcpcs": "99284", "service_date": "2024-03-10", "units": 1, "total_charges": 1200 } ], "form_locator_47_total_charges": 4925, "form_locator_50_payer_name": "Blue Cross Blue Shield of Illinois", "form_locator_51_health_plan_id": "BCBSIL", "form_locator_58_insured_name": "Patricia A. Morgan", "form_locator_60_insured_certificate_number": "XYZ987654321", "form_locator_63_treatment_authorization_codes": "AUTH-2024-5678", "form_locator_66_diagnosis_version": "0", "form_locator_67_principal_diagnosis": { "code": "I21.3", "description": "ST elevation myocardial infarction of unspecified site", "poa": "Y"}, "form_locator_67a_other_diagnoses": [ { "code": "I10", "description": "Essential hypertension", "poa": "Y"}, { "code": "E11.9", "description": "Type 2 diabetes mellitus", "poa": "Y"}, { "code": "E78.5", "description": "Hyperlipidemia", "poa": "Y"} ], "form_locator_74_principal_procedure": { "code": "02703ZZ", "description": "Dilation of coronary artery, percutaneous approach", "date": "2024-03-11"}, "form_locator_76_attending_physician": { "npi": "1234567890", "name": "Dr. William Zhang, MD"}, "form_locator_77_operating_physician": { "npi": "0987654321", "name": "Dr. Lisa Huang, MD"}, "form_locator_81_code_code": "PR-1234567890"}

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