UB-04 claim form and instructions - AmeriHealth

Office of Management and Budget and the National Uniform Billing Committee have approved the UB-04 claim form , also known as the CMS-1450 form . The UB-04 claim form accommodates the National Provider Identifier (NPI) and has incorporated other important changes. Sample UB-04 forms for inpatient and outpatient claims can be found on pages 3 and UB-04 claim form and NPIThe UB-04 claim form includes several fields that accommodate the use of your NPI. Although the form accommodates the NPI, you may continue to report your current provider identification numbers in the appropriate areas of the form until otherwise notified.

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