Sample CMS 1450 (UB-04) Form: - Kyprolis-2026

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The document provides guidance on billing for the drug Kyprolis® (carfilzomib) using the CMS 1450 (UB-04) form for Medicare hospital outpatient departments. It includes instructions on coding requirements, appropriate HCPCS codes, revenue codes, and necessary patient information. Additionally, it outlines the indications, contraindications, warnings, and adverse reactions associated with Kyprolis treatment for multiple myeloma.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient’s information in fields 8 through 10, including their name, address, and birthdate.
In section 12, indicate the occurrence date and code relevant to the patient's treatment.
For billing details, fill out columns 42 and 44 with the appropriate revenue and HCPCS codes for Kyprolis. For example, use J9047 for carfilzomib.
Complete column 46 by reporting service units based on the dosage administered. Remember that one vial equals 60 units of J9047.
Finally, review all entries for accuracy before saving or exporting your completed form using our platform.

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What is the difference between the CMS 1500 form and the UB-04 CMS-1450 claim forms?

What Is the Purpose of Form G-1450? Use Form G-1450, Authorization for Credit Card Transactions, to pay the filing fee and biometric services fee (if applicable) by credit card for an application, petition, or request that you are filing with a U.S. Citizenship and Immigration Services (USCIS) Lockbox.

What is a CMS 1450 UB-04 form?

BENEFIT APPLICATION Subject to the terms and conditions of the applicable Evidence of Coverage, carfilzomib (Kyprolis) is covered under the medical benefits of the Companys Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

What is a CMS form 1450 UB-04?

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).

What form is used to submit claims for hospital services: a CMS 1450 ub04 b CMS 1500 c w 9 d CMS 485?

J9047 Carfilzomib - CanMED: HCPCS.

Who uses the CMS-1450 form?

Though many insurers accept both forms, CMS-1500 is used primarily for billing Medicare Part B and other insurance programs that cover outpatient care. UB-04 is required for billing Medicare Part A and Medicaid institutional claims.

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