Interactive 1450 (UB-04) Form

To assist electronic billing customers with error messages received on the electronic reports, an interactive 1450 (UB-04) form has been developed as a crosswalk. This crosswalk is an interactive feature that displays the appropriate loops, segments, and qualifier detail when clicking on each block of the 1450 (UB-04) sample claim form. A crosswalk chart is also available to provide a complete list of the crosswalk information.