Institutional Paper Claim Form (CMS-1450)

Institutional Paper Claim Form (CMS-1450 form), aka UB-04 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. CMS does not supply the form to providers for claim submission. 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.

Disposition of Copies of Completed Forms

The provider retains the copy designated “Institution Copy” and submits the remaining copies of the completed Form CMS-1450 to its A/B MAC (A) or (HHH), managed care plan, or other insurer. Where it knows that a managed care plan will pay the bill, it sends the bill and any necessary supporting documentation directly to the managed care plan for coverage determination, payment, and/or denial action. It sends to the A/B MAC (A) or (HHH) bills that it knows will be paid and processed by the A/B MAC (A) or (HHH).