The UB92 form had been the standard medical insurance claim form used by health care organizations and hospitals to bill insurance and Medicaid payers. In 2007, the National Uniform Billing Committee (NUBC) https://www.nubc.org officially retired the form, approving a revised version of the UB92 form currently known as the UB04 form.

This billing guide is designed to assist with the completion of the UB-04 (CMS-1450) claim form. The UB-04 uniform billing form is the standard claim form that any institutional provider can use for the billing of medical and mental health claims. Although developed by the Centers for Medicare and Medicaid (CMS), the form has become the standard form used by all insurance carriers.

Although these forms look similar, they CANNOT be used interchangeably.

The HCFA 1500 claim form, also known as CMS-1500, enables medical physicians to submit health insurance claims for reimbursement from various government insurance plans including Medicare, Medicaid and Tricare. When a physician has a private practice but performs services at an institutional facility such as a hospital or outpatient facility, the CMS-1500 form would be used to bill for their services.

The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities. This would include things like surgery, radiology, laboratory, or other facility services.

The HCFA-1500 form (CMS-1500) is used to submit charges covered under Medicare Part B. The UB-04 (CMS-1450) to submit charges under Medicare Part A.

V.02/12 - Updated July 2020

BACKGROUND INFORMATION

The 1500 Health Insurance Claim Form (1500 Claim Form) answers the needs of many health care payers. It is the basic paper claim form prescribed by many payers for claims submitted by physicians, other providers, and suppliers, and in some cases, for ambulance services.

1500 Health Insurance Claim Form Reference Instruction Manual V.02/12 - Updated July 2021.