5.7.2.6 UB-04 CMS-1450 Paper Claim Form Instructions

The following services must be billed using the UB-04 CMS-1450 paper claim form or electronic claim format when requesting payment:

•	Hospital ambulatory surgical center (HASC)

•	Home health (skilled nursing service)

•	Hospice services

•	Inpatient hospital

•	Inpatient rehabilitation

•	Outpatient hospital

•	Renal dialysis facility

Providers are responsible for obtaining these forms from a supplier of their choice.

Refer to:

Section 5.7.2.12, “UB-04 CMS-1450 Paper Claim Form Example,” on page 5‑43.