Sample CMS 1450 (UB-04) Form: - Kyprolis-2025

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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 two most common claim forms are the CMS-1500 and the UB-04. These two forms look and operate similarly, but they are not interchangeable. The UB-04 is based on the CMS-1500, but is actually a variation on itits also known as the CMS-1450 form.
Document use of product with J9047, injection, carfilzomib, 1 mg. Report unit of service. For example, 60 units for J9047 corresponds to 60 mg of KYPROLIS.
HCFA forms, also known as the CMS-1500 forms, are primarily processed by medical billing and coding professionals who work in healthcare facilities such as hospitals, clinics, and medical practices.
The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of
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The UB-04 claim form is particularly used by institutional providers like hospitals, nursing homes, rural health clinics, and rehabilitation centers.
When a physician has a private practice but performs services at an institutional facility such as a hospital or outpatient facility, the CMS-1500 form would be used to bill for their services. The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities.

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