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UB-04 Claim Form Instructions Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the service provided. NOTE:.

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Mmddyyyy Related content

UB-04 - CDC
FIRST c. d. e. OTHER PROCEDURE. NPI. CODE. DATE. DATE. FIRST. NPI b. LAST. FIRST c. NPI d...
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UB04 - Center for Health Enhancement Systems...
UB04. The standard, uniform bill (UB) for institutional healthcare providers ... The UB-04...
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R1958CP (PDF) - CMS Manual System - HHS.gov
Apr 28, 2010 — Chapter 25, “Completing and Processing the UB-04 (CMS-1450) Data...
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The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities. This would include things like surgery, radiology, laboratory, or other facility services. The HCFA-1500 form (CMS-1500) is used to submit charges covered under Medicare Part B.

The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities. This would include things like surgery, radiology, laboratory, or other facility services. The HCFA-1500 form (CMS-1500) is used to submit charges covered under Medicare Part B.

The CMS-1450 form (aka UB-04 at present) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

The CMS-1450 form is printed with “red ink” on a standard white paper. The UB-04 is the electronic version of CMS-1450 only.

The UB04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics, chronic dialysis and Adult Day Health Care).

When CMS allows a paper claim, the Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Administrative Contractors (MACs).

Right-click on an insurance claim or insurance carrier and select Print UB04 to print the UB-04 form and send it to your insurance carrier in the mail.

The UB-04 is the electronic version of CMS-1450 only.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232