Medicaid does not supply providers with Uniform Billing claim forms. Numerous venders sell CMS-1450 (UB-04 forms.) View a sample CMS-1450 (UB-04) claim form.

Complete Arkansas Medicaid program claims in accordance with the National Uniform Billing Committee UB-04 data element specifications and Arkansas Medicaid's billing instructions, requirements and regulations.

The National Uniform Billing Committee (NUBC) is a voluntary committee whose work is coordinated by the American Hospital Association (AHA) and NUBC is the official source of information regarding form CMS-1450 (the UB-04 claim form). View or print NUBC contact information.

The committee develops, maintains, and distributes to its subscribers the Official UB-04 Data Specifications Manual (UB-04 Manual) and periodic updates. The NUBC is also a vendor of CMS-1450 (UB-04) claim forms.

Following are Arkansas Medicaid's instructions for completing, in conjunction with the UB-04 Manual, a CMS-1450 (UB-04) claim form.

Please forward the original of the completed form to the Claims Department. View or print the Claims Department contact information. One copy of the claim form should be retained for your records.