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Blue Advantage® Required UB-04 Fields

Blue Cross and Blue Shield of Alabama requires paper claims and attachments to pass the same editing standard as electronically submitted claims. To ensure accurate and timely claims processing for our members and providers, Blue Cross returns all incomplete, illegible and/or inaccurate UB-04 paper claims and attachments for correction. If the necessary information is inaccurate or not submitted, you will receive a “Return to Provider Claims Report” addressed to your provider location as indicated on the incomplete claim form.

UB-04 paper claims that do not pass these requirements will need to be corrected and resubmitted as new claims, not corrected bills.

Click here to view a sample “Return to Provider Claims Report.”

All required UB-04 claim form fields must be populated regardless of the attachment data submitted. Click here to view a sample “UB-04 Claim Form” with the required highlighted fields. Click here to view a chart that identifies the required fields that providers must complete for claims to process accurately. The numbers to the left of the chart correspond to the form locator (FL) field on the claim form. If one or more of the “required” fields are left blank or are incomplete, Blue Cross will return the claim (if paper) or deny it (if electronic).

The UB-04 Required Field Information chart provides basic filing instructions providers need to submit services for payment.

Please discontinue use of UB-92 claim forms. These forms will be denied on the “Return to Provider Claims Report.”

Contact your Provider Network Services Representative if you have any questions.

Blue Advantage is a Medicare-approved PPO Plan.

Last Updated January 2014