Claim Form Information
UB04 and New CMS 1500 Forms
The Health Plan is prepared to accept the new CMS 1500 form and will be prepared to accept the UB04 form on March 1, 2007; however, required use of the forms is not necessary until May 23, 2007. Providers must continue to use Health Plan assigned provider and office numbers until May 23, 2007.
Please click below for samples of these claim forms:
UB04
CMS 1500If you have questions regarding the UB04 or new CMS 1500 forms, please contact your Provider Relations Representative.