UB-04 Hospital Claim Forms

by PMIC

UB-04 Medical Claim Form
  • Item#: 89201-89208
  • Format: Laser Sheets or Computer
  • ISBN#: N/A
  • AAPC CEU Credit(s): N/A
  • Availability: In Stock
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Your Price: $29.95 +

Product Notes: Ships Standard Ground Only.

Newly Implemented UB04 Form Replaces UB92

These forms are the "new" format. The UB-04 claim form is mandatory for all billing from May 23, 2007.

Get help choosing the right forms for your printer! Click Here for the Guide

UB-92 Hospital Claim Forms
* You can increase the quantity of packages before check-out.
Buy Now $39.95 89208 UB-04 Laser Sheets (1,000/box)
Buy Now $29.95 89201 UB-04 1-Part Continuous Feed Computer (1,000/box)
Buy Now $59.95 89202 UB-04 2-Part Continuous Feed Computer (1,000/box)
Buy Now $52.95 89203 UB-04 3-Part Continuous Feed Computer (1,000/box)
Mailing Envelopes for UB-92 Claim Forms
Buy Now $39.95 79130 Standard Claims Envelopes- Gummed (500/Pkg)
Buy Now $49.95 79133 Standard Claims Envelopes- Self Sealing (500/Pkg)
Buy Now $89.95 79139 Jumbo UB-92/UB-04 Claim Envelopes (500/Pkg)
Product not available for priority shipping. Standard ground shipping only.

CMS is implementing the new UB-04 claim form on March 1, 2007, but the form will not be mandatory until May 23, 2007. The UB-04 claim form is mandatory for all billing from May 23, 2007. All rebilling of claims should use the UB-04, even though the original claim may have been on the UB-92 claim form.

The new UB-04 claim form is redesigned to accommodate reporting of the National Provider Identifier (NPI) number. The NPI number, a requirement of the HIPAA legislation, must be used by all HIPAA covered entities.

These UB-04 hospital claim forms are available in numerous formats and conform to all the latest CMS (HCFA) health insurance claim forms printing standards. UB-04 claim forms are used by hospitals to bill inpatient facility charges. For all other services use the CMS-1500 claim form.

What is the difference in the available formats? "Computer" forms have tear off sides and produce a duplicate copy. "Laser Sheets" are used with a desk jet or ink jet printer.