UB-04 Form – Free PDF | Fill Online in Minutes

Other Form UB-04

2025 Printable Template

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Form last updated: 03/2024. Please verify this is the current version before use.

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Step 1

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Step 2

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Step 3

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What is a UB-04 used for?

The UB-04 form, also known as CMS-1450, is used by institutional providers to submit claims for reimbursement to insurance providers, including Medicare and Medicaid. It ensures that healthcare services are billed accurately, facilitating timely payments and reducing the risk of audits.

Who needs to fill out a UB-04 form

Institutional providers such as hospitals, nursing facilities, and other healthcare institutions.

How to fill out a UB-04 online?

Follow these steps to complete your UB-04 form online.

Step 1

Select the type of claim: inpatient or outpatient.

Step 2

Fill in the provider and patient information in the appropriate fields.

Step 3

Match and enter diagnoses and procedures in the designated blocks.

Step 4

Itemize services and supplies as required.

Step 5

Include necessary revenue and HCPCS codes for outpatient claims.

Step 6

Review all entries for accuracy and completeness before submission.

CMS Official Site

Frequently Asked Questions

Find quick answers to common questions about our PDF editor.

What is Form UB-04?

Form UB-04 is a medical claim form used by institutional providers to submit billing information to insurance companies.

Who is required to fill out Form UB-04?

Institutional providers like hospitals and nursing homes must complete this form.

When is Form UB-04 due?

The form must be submitted after services are provided and within the timely filing period set by each payer.

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