New 1500 Claim Form Released

On March 25, 2015, in Documents, by AQ-IQ LLC

UPDATED March, 2015:

Form Version 02/12 will replace the current CMS 1500 claim form, 08/05, effective with claims received on and after April 1, 2014:

  • Medicare will begin accepting claims on the revised form, 02/12, on January 6, 2014;
  • Medicare will continue to accept claims on the old form, 08/05, through March 31, 2014;
  • On April 1, 2014, Medicare will accept paper claims on only the revised CMS 1500 claim form, 02/12; and
  • On and after April 1, 2014, Medicare will no longer accept claims on the old CMS 1500 claim form, 08/05.

For more details on this change see this revised MLN article

Original Post (July, 2013):

In order to accommodate reporting needs for ICD-10 and other changes, the National Uniform Claim Committee has released Version 02/12 1500 Health Insurance Claim Form in early July, 2013.

During its work, the NUCC was made aware by the health care industry of two priorities that were included in the revisions to the 1500 Claim Form. The first was the addition of an indicator in Item Number 21 to identify the version of the diagnosis code set being report, i.e., ICD-9 or ICD-10. The need to identify which version of the code set is being reported will be important during the implementation period of ICD-10. The second priority was to expand the number of diagnosis codes that can be reported in Item Number 21, which was increased from 4 to 12. Additional revisions will improve the accuracy of the data reported, such as being able to identify the role of the provider reported in Item Number 17 and the specific dates reported in Item Number 14.

Here is the PDF of the revised 1500 form, including the template and grid versions:
02/12 1500 Claim Form

Note
This PDF version of the form may not print to its exact specifications and should not be used for claims submissions.

To receive copies of the 02/12 1500 Claim Form, contact:

The following change log shows all changes between the 08/05 version and 02/12 version of the form.
02/12 1500 Form Change Log

The following is the NUCC instruction manual for the 02/12 1500 Claim Form:
• v1.1 0613 0212 NUCC 1500 Instruction Manual

The following is the NUCC 1500 Claim Form Map to X12 Health Care Claim: Professional (837P) transaction:
02/12 1500 Claim Form Map to X12 837P

Read the announcement here.

Claim form FAQs are available here.

Visit NUCC site

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