UB-04 Form Printable (CMS-1450) – Fill Out and Use This PDF

The UB-04 claim form, also known as the CMS-1450, is the standard billing form used by hospitals and healthcare providers to submit claims to Medicare, Medicaid, and commercial insurers for inpatient and outpatient services. This printable UB-04 PDF allows you to view and download a blank CMS-1450 form. For detailed instructions on filling out each section, click the button below to access the form.

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UB-04 Form (CMS-1450) PDF Details

In the landscape of healthcare billing in the United States, the transition to the UB-04 claim form, also recognized as the CMS-1450, marks a pivotal evolution in institutional billing practices. Mandated by the Office of Management and Budget (OMB) and the National Uniform Billing Committee (NUBC), the adoption of this form, from March 1, 2007, reflects significant steps towards streamlining the process and accommodating the integration of the National Provider Identifier (NPI). The comprehensive UB-04 form caters to both inpatient and outpatient services, encapsulating a wide array of data requirements such as patient information, provider details, admissions data, and various codes essential for processing claims accurately. Rigorous in its design, the form includes fields for provider names, patient demographics, the type of bill, admission details, and an extensive list of condition and value codes, among others, to support the nuanced requirements of medical billing. The insistence on the usage of NPI alongside provider identification numbers underscores the form's role in the transition towards a more centralized and efficient electronic billing system. This change, exclusive since May 23, 2007, points towards a broader shift in healthcare administration, aiming to reduce complexities and improve the precision of claims processing. Moreover, the supplement of sample UB-04 forms and specific instructions for completion underlines the effort to guide healthcare providers through this detailed and critical documentation process, ensuring compliance and facilitation of timely reimbursements.

Question	Answer
Form Name	04 Form Printable
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	aia product substitution request form, 04 form, ub 04 insurance form, printable ub 04 claim form

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new UB-04 FoRm & instRuctions

The Ofice of Management and Budget (OMB) and the National Uniform Billing Committee (NUBC) previously approved the UB-04 claim form, also known as the CMS-1450 form.The UB-04 claim form accommodates the National Provider Identiier (NPI) and incorporated other important changes.This form replaced the UB-92 claim form and was phased in over a transition period beginning March 1, 2007.The UB-04 form has been used exclusively for institutional billing beginning May 23, 2007. Sample UB-04 forms for inpatient and outpatient services are enclosed.

THE UB-04 CLAIM FORM AND NPI

The UB-04 claim form includes several ields that accommodate the use of your NPI. Although the form accommodates the NPI, you must continue to report your current provider identiication numbers in the appropriate areas of the form.

UB-04 Data FielD RequiRements

FIELD LOCATION	DESCRIPTION	INPATIENT	OUTPATIENT
UB-04	DESCRIPTION	INPATIENT	OUTPATIENT
UB-04

1	Provider Name and Address	Required	Required
2	Pay-To Name and Address	Situational	Situational
3a	Patient Control Number	Required	Required
3b	Medical Record Number	Required	Required

4	Type of Bill	Required	Required

5	Federal Tax Number	Required	Required
6	Statement Covers Period	Required	Required
7	Future Use	N/A	N/A
8a	Patient ID	Situational	Situational

8b	Patient Name	Required	Required

9	Patient Address	Required	Required
10	Patient Birthdate	Required	Required
11	Patient Sex	Required	Required
12	Admission Date	Required	Required

13	Admission Hour	Required	Required

14	Type of Admission/Visit	Required	N/A
15	Source of Admission	Required	Required
16	Discharge Hour	Required	Required
17	Patient Discharge Status	Required	Required

18-28	Condition Codes	Required if Applicable	Required if Applicable

29	Accident State	Situational	Situational
30	Future Use	N/A	N/A
31-34	Occurrence Code and Dates	Required if Applicable	Required if Applicable
35-36	Occurrence Span Codes and Dates	Required if Applicable	Required if Applicable

37	Future Use	N/A	N/A

38	Subscriber Name and Address	Required	Required
39-41	Value Codes and Amounts	Required if Applicable	Required if Applicable
42	Revenue Code	Required	Required
43	Revenue Code Description	Required	Required

44	HCPCS/Rates	Required if Applicable	Required if Applicable

*For additional information on the completion of ields, please refer to the NUBC Oficial UB-04 Data Speciications Manual.

FIELD LOCATION	DESCRIPTION	INPATIENT	OUTPATIENT
UB-04	DESCRIPTION	INPATIENT	OUTPATIENT
UB-04

45	Service Date	N/A	Required

46	Units of Service	Required	Required

47	Total Charges (By Rev. Code)	Required	Required
48	Non-Covered Charges	Required if Applicable	Required if Applicable
49	Future Use	N/A	N/A
50	Payer Identiication (Name)	Required	Required
51	NPI	Required	Required

52	Release of Info Certiication	Required	Required
53	Assignment of Beneit Certiication	Required	Required
54	Prior Payments	Required if Applicable	Required if Applicable
55	Estimated Amount Due	Required	Required

56	NPI	Required	Required

57	Health Plan IDs	Required	Required
58	Insured’s Name	Required	Required
59	Patient’s Relation to the Insured	Required	Required
60	Insured’s Unique ID	Required	Required
61	Insured Group Name	Situational	Situational

62	Insured Group Number	Situational	Situational
63	Treatment Authorization Codes	Required if Applicable	Required if Applicable
64	Document Control Number	Situational	Situational
65	Employer Name	Situational	Situational

66	Diagnosis/Procedure Code Qualiier	Required	Required
67	Principal Diagnosis Code/Other Diagnosis Codes	Required	Required
68	Future Use	N/A	N/A
69	Admitting Diagnosis Code	Required	Required if Applicable
70	Patient’s Reason for Visit Code	Situational	Situational
71	PPS Code	Situational	Situational

72	External Cause of Injury Code	Situational	Situational
73	Future Use	N/A	N/A
74	Principal Procedure Code/Date	Required if Applicable	Required if Applicable
75	Future Use	N/A	N/A

76	Attending Name/ ID-Qualiier	Required	Required
77	Operating ID	Situational	Situational
78-79	Other ID	Situational	Situational
80	Remarks	Situational	Situational
81	Code-Code Field/Qualiiers
	*0-A0	N/A	N/A

	*A1-A4	Situational	Situational
	*A5-B0	N/A	N/A
	*B1-B2	Situational	Situational
	*B3	Required	Required

*For additional information on the completion of ields, please refer to the NUBC Oficial UB-04 Data Speciications Manual.

We would also like to remind you of the requirements for electronic transactions. As a reminder, Passport Health Plan strongly recommends the continued use of plan identiication numbers in addition to NPI.

837 I Data FielD RequiRements

LOOP ID

2000A

LOOP ID

2010AA

LOOP ID

2010AA

====================== 837 I ====================== BILLING TAXONOMY LOOP ======================

Loop Name	Segment Name	PRV01 Qualiier	PRV02 Qualiier	PRV03 Value
Billing/Pay-To Provider Specialty Information	PRV	BI	ZZ	= Taxonomy
Billing/Pay-To Provider Specialty Information	PRV	PT	ZZ	= Taxonomy
		PT
====================== 837 I ====================== BILLING PROVIDER LOOP ======================


Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
			24	= TAX ID
Billing Provider	NM1	85	34	= SSN
			XX	= NPI
Loop Name	Segment Name	REF01 Qualiier		REF02 Value


		SY		= SSN
Billing Provider Secondary Identiication	REF	EI		= TAX ID
		1D		= MAID

LOOP ID

2010AB

LOOP ID

2010AB

LOOP ID

2310A

LOOP ID

2310A

LOOP ID

2310E

LOOP ID

2310E

====================== 837 I ====================== PAY TO PROVIDER LOOP ======================

Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
			24	= TAX ID
Pay-To-Provider	NM1	87	34	= SSN
			XX	= NPI
Loop Name	Segment Name	REF01 Qualiier		REF02 Value


		SY
Pay-To-Provider Secondary Identiication	REF	EI
		1D

====================== 837 I ====================== ATTENDING PROVIDER LOOP ======================

Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
			24	= TAX ID
Attending Physician	NM1	82	34	= SSN
			XX	= NPI


Loop Name	Segment Name	REF01 Qualiier		REF02 Value
Attending Physician Secondary Identiication	REF	N5		= Facets ID
====================== 837 I ====================== SERVICE FACILITY LOOP ======================

Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
Loop Name	Segment Name	NM101 Qualiier	NM108 Qualiier	NM109 Value
			24	= TAX ID
Service Facility Location	NM1	82	34	= SSN
			XX	= NPI


Loop Name	Segment Name	REF01 Qualiier		REF02 Value
Service Facility Location Secondary Identiication	REF	N5		= Facets ID

Please let us know if you have any questions regarding these instructions. In addition, if you have any questions regarding the NPI, the application process, or reporting your NPIs to us, please contact your Provider Relations representative.

How to Edit 04 Form Printable Online for Free

Completing the UB-04 claim form correctly is essential for timely reimbursement. Below are the key steps for filling out each section of the CMS-1450 form.

Step 1 – Provider Information (Fields 1-8)

Enter the billing provider name, address, and telephone number in Field 1. Field 5 requires the Federal Tax Number. Field 6 is the Statement Covers Period with From and Through dates. Field 8 requires the Patient Control Number and Medical Record Number.

Step 2 – Patient Information (Fields 9-12)

Field 9 captures the patient name (last, first, middle initial). Fields 10 and 11 record the patient date of birth and sex. Field 12 is the Admission Date for inpatient claims.

Step 3 – Type of Bill Code (Field 4)

The Type of Bill (TOB) code is a four-digit code. The first digit is always zero. The second digit identifies the facility type: 1 for hospital, 2 for skilled nursing facility, 3 for home health. The third digit identifies the care type: 1 for inpatient, 3 for outpatient. The fourth digit is the billing frequency code.

Step 4 – Diagnosis and Procedure Codes (Fields 67-75)

Enter the principal diagnosis in Field 67. Additional diagnosis codes go in Fields 67A through 67Q. Operating room procedure codes go in Fields 74 and 74A. Use current ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes.

Step 5 – Revenue Codes and Charges (Fields 42-49)

Revenue codes go in Field 42. The service description goes in Field 43 and the HCPCS or CPT code goes in Field 44. Field 46 captures service units. Field 47 lists total charges for each revenue code line. The Total Charges row sums all charges.

Step 6 – Review and Submit

Review the completed UB-04 form for accuracy before submitting. Confirm all required fields are complete. Submit electronically through an approved clearinghouse or mail the paper form to the payer. Keep a copy for your records.

UB-04 Form Printable (CMS-1450) – Fill Out and Use This PDF

UB-04 Form (CMS-1450) PDF Details

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How to Edit 04 Form Printable Online for Free

Step 1 – Provider Information (Fields 1-8)

Step 2 – Patient Information (Fields 9-12)

Step 3 – Type of Bill Code (Field 4)

Step 4 – Diagnosis and Procedure Codes (Fields 67-75)

Step 5 – Revenue Codes and Charges (Fields 42-49)

Step 6 – Review and Submit

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