Ambulatory surgery center, home health care, and hospice organizations use which claim form?

• A. UB-04 claim form
• B. CMS-1500 claim form
• C. UB-92 claim form
• D. HCFA-1500 form

Answer: (A)

The form used for ambulatory surgery centers, home health care, and hospice organizations is the UB-04 claim form. This form is designed for institutional or facility providers, capturing facility charges, revenue codes, patient information, and services reported as a facility encounter. In contrast, the CMS-1500 form is for professional services billed by individual clinicians or non-facility settings. The UB-92 and HCFA-1500 are older versions of the UB-04 and CMS-1500, respectively. Since those organizations bill as facilities, they use the UB-04.