The Office of Management and Budget and the National Uniform Billing Committee have approved the UB-04 claim form, also known as the CMS-1450 form. The UB-04 claim form accommodates the National Provider Identifier (NPI) and has incorporated other important changes. Sample UB-04 forms for inpatient and outpatient claims can be found on pages 3 ...

UB-04 Form (565.0K) You can fill in this version of the forms electronically, using Adobe Form Filler, as long as you have Adobe Acrobat Reader. (If you need the latest version of the free reader, you can download it from www.adobe.com.)

The UB-04 claim form is used to request reimbursement for services rendered by the following institutions: • Inpatient hospital facilities, such as medical/surgical intensive care, burn care,

The UB-04 claim form, also known as the CMS-1450 form, is approved by the Centers for Medicare & Medicaid Services (CMS) and the National Uniform Billing Committee for facility and ancillary paper billing. Sample UB-04 forms for inpatient and …

This document explains the UB-04 claim form, which is used for submitting claims for reimbursement for specially designated facilities. The instructions included in this section are excerpts from Medicare instructions (Rev. 3709, 02-03-17) along with commentary by

The UB-04 claim form is used to submit claims for outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics and chronic dialysis centers).

Blue Shield of Oklahoma offers this guide to help you complete the UB-04 form for your patients with Blue Cross (facility) coverage. For information on the UB-04 billing form, or to obtain an Official UB-04 Data Specifications Manual,

Note: The UB-04 C MS-1450 paper claim form is limited to 28 items per outpatient claim. This limitation includes surgical proce- dures from Blocks 74 and 74a-e. If necessary, combine IV supplies and central supplies on the charge detail and consider them to be single items with the

***This UB-04 claim form MUST be completed if you have a hospital, ER, or surgical claim*** The following are instructions to submitting a claim yourself: 1. For self-submitted claims you will need to contact your provider to obtain all proper coding and information that are necessary to complete the required and/or situational fields on this form.

ub-04 cms-1450 approved omb no. 0938-0997 ™ national the certifications on the reverse apply to this bill and are made a part hereof. nubc billing committee uniform 1 3a pat. 4 type cntl # of bill b. med. rec. # 6 statement covers period 7 5 fed. tax no. from through 8 patient aname b birthdate 11 sex 12 date 31 occurrence codedate 32 occurrence