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.
Read Full Description
- 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
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Choose the Correct Forms
- Identify the type of printer you use with the pictures below.
- Select the correct form: CMS-1500, UB-04, or Dental.
- For continuous form printers (dot matrix), select the number of parts.
Continuous Feed Printer
If you use a dot matrix printer (AKA pin or tractor feed) as pictured, choose continuous forms:
- #89110: CMS-1500 1-Part Continuous
- #89115: CMS-1500 2-Part Continuous
- #89120: CMS-1500 3-Part Continuous
- #89130: CMS-1500 1-Part Continuous w/ Mailing Label
- #89135: CMS-1500 2-Part Continuous w/ Mailing Label
- #89201: UB-04 1-Part Continuous
- #89202: UB-04 2-Part Continuous
- #89203: UB-04 3-Part Continuous
- #89634: Dental Form 1-Part Continuous
- #89636: Dental Form 2-Part Continuous
Sheet Fed Printer
If you use a sheet fed printer as pictured, choose 1 Part forms:
- #89105: CMS-1500 Laser Sheets
- #89208: UB-04 Laser Sheets
- #89535: Dental Form Laser Sheets
Laser Printer
If you use a laser / ink jet printer as pictured, choose 1 Part forms:
- #89105: CMS-1500 Laser Sheets
- #89208: UB-04 Laser Sheets
- #89535: Dental Form Laser Sheets
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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