CMS 1500 Claim Form

Use version 02/12 for claim billing by physicians and suppliers

CMS 1500.

The CMS 1500 is the red ink on white paper standard claim form used by physicians and suppliers for claim billing. Although it was developed by The Centers for Medicare and Medicaid (CMS), it has become the standard form used by all insurance carriers. As of April 1, 2014, the revised version 02/12 is the only one accepted by Medicare. The older version 08/05 is no longer valid.

Who Can Bill Claims Using the CMS 1500?

Any non-institutional provider and supplier can use the CMS 1500 for billing medical claims.

  • Physician services
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Nurse midwives
  • Certified registered nurse anesthetists
  • Clinical psychologists
  • Clinical social workers
  • Home dialysis supplies and equipment
  • Ambulance services
  • Clinical diagnostic laboratory services

Tips for Preparing the CMS 1500 Claim Form

  • Ensure that all data is entered correctly and accurately in the correct fields.
  • Enter insurance information including the patient's name exactly as it appears on the insurance card.
  • Use correct diagnosis codes (ICD-9) and procedure codes (CPT/HCPCS) using modifiers when required.
  • Use only the physical address for the service facility location field.
  • Don't forget to include NPI information where indicated.

More detailed instructions can be found at www.cms.gov or www.nucc.org

Revision of the CMS 1500 - Version 02/12

Effective January 6, 2014, the revised version (02/12) of the CMS 1500 form was approved for use.

 The revised CMS 1500 form (version 02/12) was developed to align with the format changes in electronic billing from version 4010 to version 5010 of 837P and the change from ICD 9 to ICD 10.

The form was launched January 6, 2014. As of April 1, 2014, providers can only use the revised CMS 1500 form (version 02/12).

Any remaining stocks of 08/05 should not be used.

Differences Between Version 08/05 and Version 02/12

  1. The Header: the rectangular symbol was replaced with a QR code.
  2. Field Locator 1: TRICARE CHAMPUS was replaced with TRICARE; SSN was replaced with ID#
  3. Field Locator 8: PATIENT STATUS was replaced with RESERVED FOR NUCC USE
  4. Field Locator 9b: OTHER INSURED’S DATE OF BIRTH, SEX was replaced with RESERVED FOR NUCC USE
  5. Field Locator 9c: EMPLOYER’S NAME OR SCHOOL was replaced with RESERVED FOR NUCC USE
  6. Field Locator 10d: RESERVED FOR LOCAL USE was replaced with CLAIM CODES (Designated by NUCC)
  7. Field Locator 11b: EMPLOYER’S NAME OR SCHOOL was replaced with OTHER CLAIM ID (Designated by NUCC); a dotted line was added to accommodate the use of a 2-digit qualifier
  8. Field Locator 14: DATE OF CURRENT (red arrow) ILLNESS (first symptom) OR INJURY (accident) OR PREGNANCY (LMP)  was replaced with DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP); QUAL was added, and a dotted line was added to accommodate the use of a 3-digit qualifier
  9. Field Locator 15: IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE was replaced with OTHER DATE; QUAL was added, and a dotted line was added to accommodate the use of a 3-digit qualifier
  1. Field Locator 17: a dotted line was added to accommodate the use of a 2-digit qualifier
  2. Field Locator 19: RESERVED FOR LOCAL USE was replaced with ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
  3. Field Locator 21: ICD Ind. was added and a dotted line was added to accommodate the use of a 1-digit qualifier; 8 additional lines was added for diagnosis codes; labels for diagnosis code lines was changed from numbers to alphas
  4. Field Locator 22: MEDICAID RESUBMISSION was replaced with RESUBMISSION
  5. Field Locator 30: BALANCE DUE was replaced with Rsvd for NUCC Use

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