UB-04 Claim Form / CMS 1450

What is UB-04 PDF Form?

Blank UB-04 form also known as CMS 1450 Form PDF is a one-page document institutional providers use to file various claims against Medicare, Medicaid, Tricare, and other insurance carriers. Multiple CMS encodings are used for filling, which you can find in the Medicare Claims Processing Manual (Chapter 25). This document is sometimes referred to as UB-04 (they are the same form).

What do I need the printable UB 04 form for?

• Institutional providers use this blank, such as hospitals, nursing facilities, hospices, critical care facilities, and other healthcare institutions.
• CMS 1450 or UB 04 Form is used for billing the so-called Medicare and Medicaid fiscal intermediaries, i.e., insurance carriers and providers.
• This form can only be used when the described institutional providers have a waiver from the ASCA; that is, they can use hard copies instead of submitting claims electronically.

How to Fill Out UB-04 Claim Form?

1. Fill in the UB-04 PDF form with your facility name and address and the address where the payment should be sent.
2. Fill in patient details: name, address, date of birth, gender, control number, medical record number, and so on.
3. Enter information about the date, time, and reason for the patient's admission to your facility and discharge data.
4. Use codes to describe the patient's stay at your facility and treatments performed during the billing time. Calculate totals.
5. Enter payer details: name, health plan ID, etc. List the doctors and other professionals who have treated the patient. If you have additional comments, leave them in the appropriate field UB 04 form printable finished document.

Organizations that work with UB 04 form fillable

• All insurance carriers