Get Red And White Ub 04 Form Pdf

The UB-04 claim form is used to submit claims for outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics and chronic dialysis centers).

The CMS-1450 form (aka UB-04 at present) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

The UB-04 is the electronic version of CMS-1450 only.

UB-04 claims data are usually summaries of all care occurring in the hospital for a particular time period, not necessarily just one encounter; alternatively several claims could all be iterations of the same hospital stay.

The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities. This would include things like surgery, radiology, laboratory, or other facility services. The HCFA-1500 form (CMS-1500) is used to submit charges covered under Medicare Part B.

Effective January 1, 2015 WSI will adopt CMS guidelines, which require red and white versions of the CMS 1500 and UB-04. WSI will not accept black and white versions of the CMS 1500 and UB-04 forms, including photocopied or faxed forms.

The UB-04 is the claim form for institutional facilities, and includes the following: Hospitals. Rehab facilities, e.g. physical therapy, occupational therapy and speech therapy. General health centers, federal health centers and rural clinics.

A number of things were added to the UB92 form when it underwent the revision to become UB04. The main change is the addition of the field in which to input a National Provider Identifier (NPI). Additional fields were also added like more diagnosis code fields.