UB-04 Hospital Claim Forms by PMIC

The latest format! UB-04 hospital insurance claim form with required National Provider Identifier (NPI). Formerly UB-92.
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  • Item#: UB892
  • Edition: New Format
  • Format: Continuous Feed
  • ISBN#: See Below
  • Availability: In Stock
  • Product Notes:
  • Ships standard ground only. Usually ships in 48 hours.

Newly Implemented UB04 Form Replaces UB92

Item # Description Price Qty
89201 UB-04 1-Part Continuous Feed Computer (1,000/box) $29.95
89202 UB-04 2-Part Continuous Feed Computer (1,000/box) $59.95
89203 UB-04 3-Part Continuous Feed Computer (1,000/box) $52.95
89208 UB-04 Laser Sheets (1,000/box) $39.95

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

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.

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