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Click ‘Get Form’ to open the sample UB-04 claim form in our editor.
Begin by entering the provider's information at the top, including the name and address of Anywhere Medical Center. Ensure accuracy for seamless processing.
In the 'Bill Type' section, select '13X' to indicate a hospital outpatient claim. This is crucial for proper categorization.
Fill in patient details under 'Patient Name' and 'Address'. Make sure to include all relevant identifiers for clarity.
For services rendered, input the procedure performed, such as 'Catheter Declotting', along with corresponding HCPCS code 'J2997'.
Specify the number of units administered in the designated field. Remember that 1 mg equals 1 unit for accurate billing.
Complete revenue codes for drugs and IV therapy accurately, ensuring compliance with coding standards.

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What color is the UB-04 claim form?

Printed in the USA by Next Day Labels TM with red OCR ink GPO standards.

What is CMS UB-04?

The UB-04 form is a standardized medical claim form used by institutional healthcare providers to submit billing information for services provided to patients.

What is the difference between CMS-1500 and UB-04?

The 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically. The Form CMS-1500 is the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed.

What information is entered in field 1 of the UB-04 form?

1. Billing Provider Name Address Enter the name and address of the hospital/facility submitting the claim. 2. Pay to Address Pay to address if different than field 1.

What is an UB04 form?

The UB-04 form, previously called the CMS-1450 form, is the standard claim form used by an institutional healthcare provider to submit inpatient and outpatient medical claims for reimbursement from insurance companies when a provider qualifies for a waiver from the ASCA requirement for electronic submission of claims.

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What is the CMS version of the UB-04 form?

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). CMS allows providers to submit a paper claim if they meet the Administrative Simplification Compliance Act (ASCA) exceptions.

Is CMS-1450 the same as UB04?

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.

Sample ub 04 form completed 2026