Health Insurance Claims Form, UB-04 CMS 1450

OMB 0720-0013

This information collection requirement is necessary for a medical institution to claim benefit under the Defense Health Agency, TRICARE, which includes the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). The information collected will be used by CHAMPUS/TRICARE contractors to determine beneficiary eligibility, other health insurance liability, certification that the beneficiary received the care and that the provider is authorized to receive CHAMPUS/TRICARE payments.

The latest form for Health Insurance Claims Form, UB-04 CMS 1450 expires 2020-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-1450 UB-04 For Health Insurance Claims Form, UB-04 CMS 1450 Form
CFR-2011-title32-vol2-sec199-14.pdf Supplementary Document
CFR-2011-title32-vol2-sec199-7.pdf Supplementary Document
OMB Supporting Statement Part A_0720-0013.doc Supporting Statement A
Health Insurance Claims Form, UB-04 CMS 1450 Form

All Historical Document Collections

201705-0720-002 Approved with change	Reinstatement with change of a previously approved collection	2017-05-12
201201-0720-001 Approved without change	Extension without change of a currently approved collection	2012-01-31
200811-0720-001 Approved without change	Extension without change of a currently approved collection	2008-11-26
200506-0720-001 Approved without change	Extension without change of a currently approved collection	2005-06-14
200201-0720-002 Approved without change	Reinstatement without change of a previously approved collection	2002-01-24
199704-0720-001 Approved without change	New collection (Request for a new OMB Control Number)	1997-04-18