Cms ub 04 claim form 2026

The document outlines the revisions to the CMS-1450 (UB04) Health Insurance Claim form, effective May 23, 2007, as approved by the Centers for Medicare & Medicaid Services (CMS). It details changes made to accommodate the National Provider Identifier (NPI) and other codes, while maintaining most data descriptions. Key updates include modifications to form locator fields, billing guidelines for providers transitioning from the UB92 to UB04 format, and specific instructions for submitting claims accurately. The document serves as a guide for institutional providers on how to complete the new claim form.

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Click ‘Get Form’ to open the CMS UB 04 claim form in our editor.
Begin by filling out Form Locator 1 with the Billing Provider's Name, Address, and Telephone Number. Ensure all details are accurate for processing.
In Form Locator 2, enter the Pay-to Name and Address. This is crucial for payment routing.
Complete Form Locators 3a and 3b with the Patient Control Number and Medical Record Number respectively to track patient information.
For Type of Bill (Form Locator 4), select the appropriate code that reflects the nature of the service provided.
Fill in patient details in Form Locators 8a through 9e, including Patient Identifier, Name, and Address. Accuracy here is vital for claims processing.
Continue filling out additional required fields such as Admission Date (FL 14) and Principal Diagnosis Code (FL 67) to ensure compliance with billing standards.

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