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Completing the UB-04 Form

This guide is designed to highlight the fields of the UB-04 Claim Form that are required when submitting to BlueShield of Northeastern New York.

BlueShield of Northeastern New York will only accept the UB-04. Providers submitting an invalid claim form will have their claims rejected and returned to them, advising to submit the proper form.

The NUBC UB-04 Health Insurance Claim Form Reference Instruction Manual is available for purchase on the NUBC website,

BlueShield of Northeastern New York prefers that providers submit their claims electronically. For more information on how to submit claims electronically, contact your EHR vendor or visit our ASK-EDI section in the Provider portal. 

Ordering Forms and Submitting Claims:

There are several ways to order UB-04 forms:

  1. Contact your current forms supplier
  2. Visit the Government Printing Office Online
  3. Call 888-512-1800

Submitting Claims:

All paper claims should be submitted to:
BlueShield of Northeastern New York
P.O. Box 80
Buffalo, New York 14240-0080

Form Completion: 

The following pages detail how to complete the UB-04 form. If you have any questions, please contact your Network Representative.

View the complete UB-04 Instruction Guide and Form below.


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