What is a UB04 vs CMS-1500?


Editorial team Published on

CMS-1500 and UB-04 are the two standard health insurance claim forms used in the United States to request reimbursement from insurance payers like Medicare, Medicaid, and private insurers.

They cannot be used interchangeably. They apply to different types of healthcare providers and settings.

CMS-1500 (Professional Claims)

  • Who uses it: Individual healthcare professionals, such as doctors, therapists, chiropractors, and private practices.
  • What it covers: Outpatient services, doctor visits, and individual professional procedures. It typically corresponds to Medicare Part B and the electronic 837P format.
  • Structure: Contains 33 fields focused on patient demographics, specific provider identifiers (like an NPI), and individual procedure codes (CPT/HCPCS and ICD-10 diagnosis codes).
  • Alternative name: Formerly known as the HCFA-1500.

UB-04 (Institutional Claims)

  • Who uses it: Healthcare institutions and facilities, such as hospitals, nursing homes, emergency departments, hospice facilities, and ambulatory surgery centers.
  • What it covers: Inpatient stays, room and board, emergency room care, and comprehensive facility resources. It typically corresponds to Medicare Part A and the electronic 837I format.
  • Structure: Contains 81 alphanumeric fields (called Form Locators) and organizes charges around departmental revenue codes rather than just individual line-item CPT codes.
  • Alternative name: Also referred to as the CMS-1450.