The Centers for Medicare and Medicaid Services (CMS) form 1450, cited as the UB-04, is the standard claim form used to bill facility services. The UB-04 uniform medical billing form is the standard claim form that any institutional provider can use for the billing of inpatient or outpatient medical and mental health claims. It is a paper claim form printed with red ink on white standard paper.
Submitting the claim form with all required fields helps in paying your claim in a timely manner. Claim forms that are missing one or more of the required fields may be rejected or denied. When completing the form be sure to include information regarding any other insurance coverage. The facility tax identification number, itemized dates of service, appropriate procedure codes, and revenue codes to assist in proper and timely payment of all claims.
Although developed by the Centers for Medicare and Medicaid Services (CMS), the form has become the standard form used by all insurance carriers.
UB-04 Claim Form Uses
UB-04 can be used by any institutional provider for billing medical claims. This includes:
- Outpatient physical therapy services
- Community mental health centers
- Rural health clinics
- Comprehensive outpatient rehabilitation facilities
- Critical access hospitals
- End-stage renal disease facilities
- Federally qualified health centers
- Histocompatibility laboratories
- Home health agencies
- Organ procurement organizations
- Occupational therapy services
- Speech pathology services
- Skilled nursing facilities
Instructions for Preparing the UB-04
To fill out the UB-04 Claim Form accurately and completely, follow the instructions:
- Enter complete insurance information including the patient’s name exactly as it is on the insurance card.
- Ensure that all data is entered correctly and accurately in the correct fields.
- Use correct diagnosis codes (ICD-10) and procedure codes (CPT/HCPCS) using modifiers when required.
- To determine the required data check with each insurance payer.
- Use only the physical address for the service facility location field.
When completing this form for all facility services rendered to a member, it is necessary to follow the instructions provided by the National Uniform Billing Committee in the latest UB-04 Data Specifications Manual.
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