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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.6 UB-04 CMS-1450 Paper Claim Filing Instructions : 6.6.2 UB-04 CMS-1450 Claim Form (Paper) Billing

Providers obtain the UB-04 CMS-1450 paper claim forms from a vendor of their choice.
To avoid claim denial, only the provider’s NPI should be placed in form locators 76-79 of the UB-04 CMS-1450 paper claim form or in the referring provider field on the electronic claim unless the client is a limited client.
Completed UB-04 CMS-1450 claims must contain the billing provider’s full name, address, and provider identifier. Claims without a provider name, address, and provider identifier cannot be processed.
Refer to:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.