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December 2016 Texas Medicaid Provider Procedures Manual

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 (TPI/NPI in the appropriate fields). Claims without a provider name, address, and provider identifier in the appropriate fields cannot be processed.
Refer to:
The Institutional paper claim form (CMS-1450) CMS website at for more information about the CMS-1500 paper claim form. Providers can purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. Providers can find examples of completed claim forms on the Claim Form Examples page of the TMHP website at
subsection 6.6.3, “UB-04 CMS-1450 Instruction Table” in this section.

Texas Medicaid & Healthcare Partnership
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