UB-04 Form

CMS-1500 Form

UB-04 Form

FDA Approval Letter

Correctly coded claim forms facilitate the claims process and decrease the likelihood of having claims denied. Below is the downloadable UB-04 form designed to facilitate successful claim submissions. Examples of claim forms and potential codes that may be appropriate when billing for Cathflo and related services are included as well.

Note: Select the appropriate billing code when filing all claims. Billing codes should be based on diagnosis and the services provided.

Example of UB-04 (PDF)

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How to complete the UB-04

The UB-04 is the form accepted by CMS for hospitals to use when billing Medicare Fiscal Intermediaries (FI). UB-04 forms can be submitted either electronically or on paper ("hard copy"). The UB-04 was adopted in 2007 to replace the UB-92.

Providers billing with the UB-04 must supply specific information about the patient, the patient's insurance, and about themselves as service providers. The service provided is described by revenue codes, revenue code descriptions, and HCPCS. The number of services rendered and the charge for these services depends on the facility's charge master.

The submission criteria for completing the UB-04 form may vary. To ensure all local submission criteria are met, providers should contact their representative before submitting claims.