UB-04 (CMS 1450) Health Insurance Claim Form.
The CMS-1450 form (aka UB-04 at present) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It is also used for billing of institutional charges to most Medicaid State Agencies.
- Box with 2,500 forms.
UB-04 (CMS 1450) Medical Claim Form