Which fields are left blank at this time on the UB-04 form?

Which fields are left blank at this time on the UB-04 form?

• A. FL 30 and FL 37
• B. FL 31-34
• C. FL 38
• D. FL 42

Answer: (A)

On the UB-04 form, not every field must be filled. Some form locators are optional or reserved for special circumstances, so they’re left blank when the information isn’t applicable or required for the claim being submitted. In this scenario, the two locations are typically not needed for a standard inpatient hospital claim under the current submission guidelines, so they’re left empty to reflect that no additional data is available or necessary at this time. The essential data—like patient identifiers, admission/discharge dates, and the diagnosis and procedure codes—are still completed to ensure the claim can be processed.

On the UB-04 form, not every field must be filled. Some form locators are optional or reserved for special circumstances, so they’re left blank when the information isn’t applicable or required for the claim being submitted. In this scenario, the two locations are typically not needed for a standard inpatient hospital claim under the current submission guidelines, so they’re left empty to reflect that no additional data is available or necessary at this time. The essential data—like patient identifiers, admission/discharge dates, and the diagnosis and procedure codes—are still completed to ensure the claim can be processed.