Updates to the CMS 1500 Health Insurance Claim Form

cms 1500

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)

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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. (Blue Cross Blue Shield, Texas)

The CMS 1500 claim form is designed for physicians and suppliers to provide information on Medicare, Medicaid, and other health insurance.
This information is used to determine whether the Medicare patient has other coverage that must be billed before Medicare makes a payment, or if Medicare can forward billing and payment data to another insurer (that’s assuming the provider is a physician or supplier that participates in Medicare).

Tips to keep in mind while filling this form our for your Medicare patients:

  1. Make sure you enter the patient’s 8-digit birthday in every single birth field. (May 26, 1932 = 05|26|1952)
  2. If a claim is submitted with incomplete or invalid information, it won’t be processed at all. It’ll get returned to your office, and you’ll have to start over.
  3. Whether Medicare is the primary or secondary payer, the Health Insurance Claim Number (HICN) is required on the form, so don’t leave it out.
  4. Always enter the patient’s information as it’s shown on their Medicare card, just to avoid confusion.
  5. Your patient may get their insurance through a spouse. In Item #4 of Section 10.2, enter the name of the spouse if the spouse’s insurance is the primary one for the patient APART from Medicare. If the patient and the insured are the same, simply write SAME. If the patient’s primary coverage is Medicare, just leave it blank.
  6. For tips like these, and step by step guidelines on completing your CMS 1500 forms, check out this CMS instruction manual.