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The CMS-1450 form (aka UB-92 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. Please contact your Medicaid State Agency for more details on their requirements for this paper form.
The National Uniform Billing Committee (NUBC) is responsible for the design of the form, and award of the contract for printing of the form. You may obtain copies of the CMS-1450 form, which is also known as the UB-92, from the Standard Register Company, Forms Division. Their phone number may be found in your local yellow pages. Blank copies of the form may also be available through office supply stores in your geographic area. Although a copy of that form can be downloaded, copies of the form should not be downloaded for submission of claims, since your copy may not accurately replicate colors included in the form. These colors are needed to enable automated reading of information on the form.
You can find Medicare CMS-1450 UB-92 completion and coding instructions in Chapter 25 of the Medicare Claims Processing Manual (Pub.100-04). The UB-92 will not be accepted by CMS after May 22, 2007.
The NUBC is updating the UB-92; it will be replaced by the UB-04 paper form. During the period March 1, 2007 through May 22, 2007, providers that use paper forms for claim submission will be able to submit either the UB-92 or the UB-04 form. CMS expects to discontinue acceptance of UB-92 forms effective May 23, 2007. HIPAA requires submission of National Provider Identifiers (NPIs) on claims effective May 23, 2007, and the UB-92 does not have a field for reporting of NPIs. The dates of this transition period were established by the NUBC. Further information on the UB-92 and the UB-04 is available through the NUBC web site. A link is provided below. The UB-04 will retain the CMS-1450 designation.
CMS has received Office and Management and Budget approval for the UB-04, as required under the Paperwork Reduction Act. You can find Medicare CMS-1450 UB-04 completion and coding instructions in Chapter 25 of the Medicare Claims Processing Manual (Pub.100-04). The UB-04 will be the only hardcopy claims format accepted by CMS after May 22, 2007. See Medicare Claims Processing Manual, (Pub.100-04), Chapter 25 for further information.
Page Last Modified: 10/16/2008 9:26:47 AM
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