This consists of 100 original, blank single sheets of the February 2012 Revision of the official CMS-1500 Medicare and Medicaid health insurance claim form required by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health & Human Services. (Sold only in packages of 100 blank forms under this stock number.)
What is the CMS-1500 Form? The CMS-1500 form is the standard claim form developed by the National Uniform Claim Committee (NUCC) and used by all non-institutional medical provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It is also used for billing of some Medicaid State Agencies (contact your Medicaid State Agency for more details).
Formats: Printed copies of the CMS-1500 claim form come in various configurations: single part, multi-part, continuous feed, laser, etc.
What has changed in the Form for 2014: The revised form has a number of changes. Those most notable for Medicare are new indicators to differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.
Important dates to note: The National Uniform Claim Committee (NUCC) recently revised Form CMS-1500. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. This form replaces the current Form CMS-1500, 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. However, 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 Form 1500, 02/12. On and after April 1, 2014, Medicare will no longer accept claims on the old Form CMS-1500, 08/05.
Why photocopies of blank forms cannot be used: The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, copies of the form cannot be used for submission of claims, since your photocopy may not accurately replicate the scale and OCR color of the form. The majority of paper claims sent to carriers and DMERCs are scanned using Optical Character Recognition (OCR) technology. This scanning technology allows for the data contents contained on the form to be read while the actual form fields, headings, and lines remain invisible to the scanner. Photocopies cannot be scanned and therefore are not accepted by all carriers and DMERCs.
Where to go for additional instructions on how to use the Revised Form: For Medicare/ Medicaid Claims Processors who need more information and guidelines on how to submit data on the revised form, read the Form CMS-1500 Instructions: Revised for Form Version 02/12.
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- Health and Human Services Dept., Centers for Medicare and Medicaid Services
- Although the CMS-1500 form (02-12) is effective January 6, 2014, use of the revised form is optional until March 31, 2014.
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- Form CMS 1500Health Insurance
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- 1.0625 lb.
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