UB04 Field 1: Rendering Provider Name and Address

Overview

Field 1 on the UB-04 claim form is titled “Billing Provider Name, Address, and Telephone Number.” According to the Maryland Medicaid instructions, this field is Required for both inpatient and outpatient claims. The provider must enter the name, phone number, and service location of the entity submitting the bill. ^[1]

• Line 1: Enter the provider name as it is filed with the Medical Assistance Program.
• Line 2: Enter the street address to which the invoice should be returned if it is rejected due to provider error.
• Line 3: Enter the city, state, and full nine‑digit ZIP Code.
• Line 4: Telephone, fax, and county code (optional).

A critical note from the source states that checks and remittance advice are sent to the provider’s address as it appears in the Program’s provider master file, not necessarily to the address entered on this field. ^[1]

When to Use

Field 1 is required on every UB-04 claim for both inpatient and outpatient services. It identifies the billing provider to the payer and serves as the return address for rejected invoices. Use this field when submitting claims to Maryland Medicaid. ^[1]

The field is not to be confused with the “Pay‑to Name and Address” (FL 02) which is reserved for internal payer use and must be left blank. ^[1]

Step‑by‑Step Claim Example

Assume a hospital named “Mercy General Hospital” is submitting a UB-04 for an inpatient stay. The provider’s enrolled name and address are:

• Line 1: Mercy General Hospital
• Line 2: 123 Main Street
• Line 3: Baltimore, MD 21201-1234
• Line 4: (410) 555-0199

Steps:

1. On the UB-04 form, locate FL 01 (Box 1).
2. In Line 1, type the exact name as registered with the payer’s provider master file: “Mercy General Hospital.”
3. In Line 2, enter the street address where returned invoices should be sent: “123 Main Street.”
4. In Line 3, enter “Baltimore, MD 21201-1234.”
5. In Line 4, optionally enter the telephone number “(410) 555-0199.”
6. Verify that the address on Line 2‑3 matches the address on file with the payer for remittance purposes, as remittance advices and checks are sent to that file address, not necessarily the address entered here. ^[1]

Common Mistakes & Audit Red Flags

• Mismatched Provider Name: Using a trade name different from the name on file with the payer. This can cause claim rejection or delayed payment. ^[1]
• Incorrect Return Address: If the address on Line 2‑3 does not match the provider’s master file address, returned invoices may be lost. The payer uses the master file address for remittance, not the address in FL 01. ^[1]
• Missing Required Elements: Failing to populate all required lines (especially Line 1 and Line 3) may result in an incomplete claim. The field is required for both inpatient and outpatient, so omission is an immediate audit flag. ^[1]
• Using Box 1 for Rendering Provider: This field is for the billing provider, not the individual who rendered the service. Mixing these up can lead to payer edits and denials. (Note: The source does not define “rendering provider” in this context; the field is explicitly “Billing Provider.”)

Related Codes/Fields

The table below lists UB-04 form locators that interact with or are commonly confused with Field 1.

Form Locator	Field Title	Relationship to Field 1	Source
FL 02	Pay‑to Name and Address	Reserved for internal payer use; must be left blank on the provider’s form.	[1]
FL 03a	Patient Control Number	Required; uniquely identifies the patient for the billing provider.	[1]
FL 76	Attending/Referring/Rendering Provider	Identifies the individual rendering services; distinct from the billing entity in FL 01.	Not directly covered in provided sources; standard UB-04 definition.
FL 81	Code (Taxonomy)	Provider taxonomy code that should align with the billing provider’s specialty.	Not covered in provided sources.

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References

[1] Maryland Medicaid — FL 1 — https://health.maryland.gov/mmcp/provider/Documents/ffs-billing/UB04-Hospital-Billing-Instructions%20%281%29.pdf