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Ub 04 claim form 2026

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The document provides an overview of the UB-04 claim form, also known as the CMS-1450 form, which has been approved by the Office of Management and Budget and the National Uniform Billing Committee. It details the incorporation of the National Provider Identifier (NPI) into the form and outlines various data field requirements for both inpatient and outpatient claims. Additionally, it includes instructions for reporting NPIs and contact information for inquiries.

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Click ‘Get Form’ to open the UB-04 claim form in our editor.
Begin by filling out the Provider Name and Address in field 1. Ensure that all information is accurate to avoid processing delays.
In field 2, enter the Pay-To Name and Address. This should reflect where payments should be directed.
Complete fields 3a and 3b with the Patient Control Number and Medical Record Number respectively, which are essential for tracking the claim.
Fill in field 4 with the Type of Bill, indicating whether it’s an inpatient or outpatient service.
Continue through each section, ensuring you provide required information such as Patient ID, Admission Date, and Diagnosis Codes as specified in the form.
Review all entries for accuracy before submitting your claim. Utilize our platform's features to save your progress or make edits easily.

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2009	4.9 Satisfied (305 Votes)

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