PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 02-12 CARRIER HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE NUCC 02/12 PICA MEDICAID TRICARE ID /DoD GROUP HEALTH PLAN ID CHAMPVA Medicaid Member ID FECA BLK LUNG 3. PATIENT S BIRTH DATE DD YY MM 2. PATIENT S NAME Last Name First Name Middle Initial F 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE ZIP CODE 4. INSURED S NAME Last Name First Name Middle Initial SEX M 5. PATIENT S ADDRESS No* Street Child Spouse...
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Updates to the CMS 1500 Health Insurance Claim Form

This year, the National Uniform Claim Committee (NUCC) made several necessary updates to the standard CMS 1500 Health Insurance Claim Form. These changes were made primarily in response to new guidelines established by the Centers for Medicare and Medicaid Services (CMS) to work better  the electronic Health Care Claims system.

On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised CMS-1500 paper claim form, known as OMB-0938-1197 FORM 1500 (02-12). (You’ll see this new code at the bottom of the revised version.)

Changes you may notice on the new form:

  • Indicators added for differentiating between ICD-9-CM and ICD-10-CM diagnosis codes
  • The number of possible diagnosis codes expanded to 12
  • Qualifiers added to identify provider roles (ordering, referring, supervising)

For consistency with electronic transactions, the revised paper form also aligns with the requirements of the Accredited Standard Committee X12 (ASC X12) Health Care Claim: Professional (837P) Version 5010 Technical Reports Type 3 (TR3s). Several fields on the previous paper form were removed for CMS-1500 (version 02/12) since they are not reported in the 837 transaction. (Click here to start digitally filling out your patients’ CMS-1500 Health Insurance Claim Forms

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