UB-04 Billing Claim Form – Paper forms – FREE Priority Shipping

Description

The UB-04 Billing Claim Form, also known as the CMS-1450 Form, is the universal paper claim used to bill for medical and mental health services.  The uniform bill (UB) is used by hospitals, nursing homes, hospice, home health agencies, and other institutional providers who are submitting a paper claim. The UB-04 is the only paper claim is accepted by the Centers for Medicare & Medicaid Services (CMS) from institutional providers who qualify for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

Any institutional provider can use the UB-04 for billing medical claims.
Institutional providers include hospitals, Skilled Nursing Facilities (SNFs), End Stage Renal Disease (ESRD) providers, Home Health Agencies (HHAs), hospices, outpatient rehabilitation clinics, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Community Mental Health Centers (CMHCs), Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), histocompatibility laboratories, Indian Health Service (IHS) facilities, organ procurement organizations, Religious Non-Medical Health Care Institutions (RNHCIs), and Rural Health Clinics (RHCs).