Form · Claims

UB-04 claim form (CMS-1450)

What it is, who uses it, and field-by-field help. Publisher: National Uniform Billing Committee (NUBC); Medicare instructions from CMS. Links checked October 23, 2026.

Quick answer

The UB-04, which keeps the CMS-1450 designation, is the paper claim for institutional providers such as hospitals and skilled nursing facilities. The National Uniform Billing Committee (NUBC) designs it and owns its code lists. Medicare takes it only from providers with a waiver from electronic billing; most institutional claims go as the 837I.

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At a glance

Form: UB-04, CMS-1450 designation
Used for: Institutional claims (electronic version: ASC X12 837I)
Form locators: 81 (FL 1 to FL 81)
Codes on the form: Defined by NUBC in the UB-04 Data Specifications Manual (licensed)
Medicare instructions: Claims Processing Manual ch. 25
Government form: None published nationally; see the links below

Who uses it

Hospitals (inpatient and outpatient), skilled nursing facilities, home health agencies, and hospices
Institutional providers billing Medicare on paper under an ASCA waiver
Most state Medicaid agencies, for institutional charges (per CMS)

Provider, patient, and stay (FL 1 to FL 17)

FL 1 and FL 2. Billing and pay-to provider: Name, address, and phone of the billing provider, and a separate pay-to address if payment goes elsewhere.
FL 3a and 3b. Patient control and record numbers: Your account number and medical record number for the stay.
FL 4. Type of bill: A four-character code that tells the payer the facility type, the bill classification, and whether it is an original, a replacement, or a void. NUBC defines the values.
FL 5 and FL 6. Federal tax number and statement period: The provider's tax ID and the from and through dates the claim covers.
FL 8 to FL 11. Patient: Name, address, birth date, and sex.
FL 12 to FL 17. Admission and discharge: Admission date and hour, priority (type) of admission, point of origin, discharge hour, and discharge status, each coded per NUBC.

Condition, occurrence, and value codes (FL 18 to FL 41)

FL 18 to FL 28. Condition codes: Up to 11 codes describing conditions that affect payment. Values come from NUBC; this page does not list them.
FL 31 to FL 36. Occurrence codes and spans: Codes with dates (or date spans) for events tied to the claim, such as an accident date.
FL 38. Responsible party: Name and address of the party responsible for the bill.
FL 39 to FL 41. Value codes and amounts: Codes with dollar or unit amounts the payer needs to price the claim.

Service lines (FL 42 to FL 49, 22 lines)

FL 42 and FL 43. Revenue code and description: A revenue code for each line (from NUBC) and its description.
FL 44. HCPCS, rates, or HIPPS code: The HCPCS code for outpatient lines, the accommodation rate for inpatient room lines, or a HIPPS code.
FL 45 to FL 48. Dates, units, and charges: Service date, service units, total charges, and non-covered charges for each line.

Payer, diagnosis, and providers (FL 50 to FL 81)

FL 50 to FL 55. Payer: Payer name, health plan ID, release of information and assignment of benefits indicators, prior payments, and estimated amount due.
FL 56 and FL 57. NPI and other IDs: The billing provider's NPI and any other provider ID a payer requires.
FL 58 to FL 65. Insured: Insured's name, relationship, unique ID, group name and number, treatment authorization code, document control number, and employer.
FL 66 and FL 67. Diagnosis codes: The ICD version indicator and the principal diagnosis with its present-on-admission indicator, then other diagnoses.
FL 74. Principal procedure: The principal inpatient procedure code (ICD-10-PCS) and date.
FL 76 to FL 79. Attending, operating, and other providers: Names and NPIs of the attending physician, operating physician, and other providers.
FL 80 and FL 81. Remarks and code-code: Free-text remarks and an overflow field for extra codes with qualifiers.

Questions

Can I download the UB-04 and use it?

CMS says not to download copies for submitting claims, because a downloaded copy may not reproduce the red ink the scanners need. CMS does not supply the form; it is sold by printers and office suppliers.

Where are the UB-04 revenue codes and type of bill codes?

NUBC defines them in its licensed UB-04 Data Specifications Manual. This page explains the form without reproducing NUBC code tables.

Is the UB-04 the same as the CMS-1450?

Yes. CMS says the UB-04 keeps the CMS-1450 designation.