UB-04 Hospital Claim Form for Dot-Matrix Printers, 3-Part

Printed with red ink on white carbonless 20-lb. paper for trouble-free use in your printer.

The UB-04 contains a number of improvements and enhancements that include better alignment with the electronic HIPAA ASC X12N 837-Institutional Transaction Standard. The New UB-04 paper billing form will be able to accommodate the reporting of the National Provider Identifier (NPI) Number. The NPI will be a single provider identifier, replacing the different provider identifiers healthcare systems currently use for each health plan with which you do business. The NPI Identifier, which implements a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), must be used by all HIPAA covered entities, which are health plans, healthcare clearinghouses, and healthcare providers.

The new UB-04 form will be effective for optional use starting March 1, 2007 through May 23, 2007 but will be required starting May 23, 2007.

All rebilling of claims should use the UB-04 billing form from this date forward, even though earlier submissions may have been on the UB-92.

• Easily file a medical claim with a patient's insurance carrier
• File a hard copy of each claim with patient records in case you need to resubmit a claim
• 3-Part forms
• Continuous forms, compatible with Dot-Matrix printers