UB-04 Hospital Claim Forms by PMIC

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.