UB04 Form

UB04 Claim Forms

$48.40$52.40

The UB-04, also known as the Form CMS-1450, is the uniform institutional provider hardcopy claim form suitable for use in billing multiple third party payers. Unique to Medicare is that the Administrative Simplification Compliance Act (ASCA) prohibits payment of services or supplies for initial claims that a provider did not bill electronically. The UB-04 is the only hardcopy claim form that the Centers for Medicare & Medicaid Services (CMS) accepts from institutional providers (e.g., hospitals, Skilled Nursing Facilities, Home Health Agencies, etc.) which meet the ASCA exceptions or which have been granted a waiver. Learn more about the ASCA.UB04 Claim Forms come in three styles:

  • 1 Part Laser InkJet – 2500 sheets
  • 2 Part Continuous perforated Dot Matrix – 1000 sheets
  • 1 Part Continuous perforated Dot Matrix – 2500 sheets
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Description

The UB-04, also known as the Form CMS-1450, is the uniform institutional provider hardcopy claim form suitable for use in billing multiple third party payers. Unique to Medicare is that the Administrative Simplification Compliance Act (ASCA) prohibits payment of services or supplies for initial claims that a provider did not bill electronically. The UB-04 is the only hardcopy claim form that the Centers for Medicare & Medicaid Services (CMS) accepts from institutional providers (e.g., hospitals, Skilled Nursing Facilities, Home Health Agencies, etc.) which meet the ASCA exceptions or which have been granted a waiver. Learn more about the ASCA.

UB04 Claim Forms come in three styles:

  • 1 Part Laser InkJet – 2500 sheets
  • 2 Part Continuous perforated Dot Matrix – 1000 sheets
  • 1 Part Continuous perforated Dot Matrix – 2500 sheets

Additional information

Style

1 Part Laser InkJet – 2500 sheets, 2 Part Continuous – 1000 sheets, 1 Part Continuous – 2500 sheets

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