UB-04 / CMS-1450

Standard paper claim form for institutional (hospital, SNF, home health) billing. 81 form locators. Includes patient information, occurrence/condition codes, value codes, revenue codes, HCPCS, units, charges, payer information, and ICD-10 diagnoses with POA indicators. Electronic equivalent is the 837I transaction. Required for all hospital inpatient and outpatient billing.