Get Ub94

The Ub94 form, also known as the CMS-1450, is essential for healthcare providers to submit claims to Medicare and Medicaid. This guide will walk you through each section of the form, ensuring you complete it accurately and efficiently online.

Follow the steps to fill out the Ub94 form online.

1. Click ‘Get Form’ button to obtain the Ub94 form and open it in the online editing tool.
2. Complete the billing provider information with the physical address where services were provided. Do not use a Post Office Box.
3. Enter the pay-to provider information if it differs from the billing provider. Note that a PO Box is acceptable here.
4. Fill in the patient control number if the pay-to provider's address is different from the billing provider's.
5. Input the bill type based on the patient account number, using acceptable values from the NUBC taxonomy tables.
6. Enter the federal tax ID for identification purposes.
7. Specify the statement covers from and through dates using the format MMDDYY without any separators.
8. Include the unassigned patient ID number without hyphens, ensuring accuracy for claim adjudication.
9. Complete the patient name and address, ensuring all fields are filled accurately.
10. Provide the patient's date of birth, sex, admission or start of care date, and admission hour as required.
11. Fill in details regarding admission type, source, discharge hour, and discharge status as appropriate.
12. Add occurrence codes and dates where required, ensuring to use correct state abbreviations for accidents.
13. Input the values, revenue codes, HCPCS codes, and service dates necessary for the claim.
14. Complete any remaining fields, including the release of information, benefits assigned, and the attending provider's identifiers.
15. Once you have filled in all required fields, save your changes, then download, print, or share the completed form as needed.

Begin your process of completing the Ub94 form online today.