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UB-04 ( New UB-92 / CMS-1450 )
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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 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.
THIS PRODUCT HAS A 20% RESTOCKING FEE IF ORDERED INCORRECTLY, FREIGHT IS NON-REFUNDABLE.
Item #: UB-04-LAS
Laser Cut Sheet 8-1/2 x 11 20# Bond Red Ink
ACS Low Prices
Price is per case,
2500
per case
1 - 2 : $43.00
3 - 5 : $41.00
6 or more : $38.00
Item #: UB-04-1
Continuous 1 Part 9-1/2 X 11 20# Bond Red Ink
ACS Low Prices
Price is per case,
2500
per case
1 - 2 : $44.00
3 - 5 : $42.00
6 or more : $40.00
Item #: UB-04-2
Continuous 2 Part 9-1/2 X 11 20# Bond Red Ink
ACS Low Prices
Price is per case,
1000
per case
1 - 2 : $44.00
3 - 5 : $42.00
6 or more : $40.00
Item #: UB-04-3
Continuous 3 Part 9-1/2 X 11 20# Bond Red Ink
ACS Low Prices
Price is per case,
1000
per case
1 - 2 : $89.00
3 - 5 : $87.00
6 or more : $85.00
Item #: UB-04-4
Continuous 4 Part 9-1/2 X 11 20# Bond Red Ink
ACS Low Prices
Price is per case,
500
per case
1 - 2 : $55.00
3 - 5 : $53.00
6 or more : $51.00
Item #: UB-04-5
Continuous 5 Part 9-1/2 X 11 20# Bond Red Ink
ACS Low Prices
Price is per case,
500
per case
1 - 2 : $65.00
3 - 5 : $63.00
6 or more : $61.00
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