June 17, 2013

The NUCC is pleased to announce the final approval of the Version 02/12 1500 Health Insurance Claim Form (1500 Claim Form) that accommodates reporting needs for ICD-10 and aligns with requirements in the Accredited Standards Committee X12 (ASC X12) Health Care Claim: Professional (837P) Version 5010 Technical Report Type 3. The Office of Management and Budget (OMB) has approved the 1500 Claim Form under OMB Number 0938-1197.

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:

  • Your current forms supplier;
  • TFP Data Systems: This email address is being protected from spambots. You need JavaScript enabled to view it. or 800-482-9367 ext. 58029; or
  • The Government Printing Office: http://bookstore.gpo.gov/catalog/government-forms-phone-directories or 866-512-1800

TFP will have the print files and specifications available as of June 20, 2013.

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

Medicare Transition Timeline

The Centers for Medicare & Medicaid Services (CMS) announced in the CMS Medicare Learning Network on June 27, 2013 that their tentative timeline for implementing the 02/12 1500 claim form is as follows:

  • January 6, 2014: Medicare begins receiving and processing paper claims submitted on the revised CMS 1500 claim form (version 02/12).
  • January 6 through March 31, 2014: Dual use period during which Medicare continues to receive and process paper claims submitted on the old CMS 1500 claim form (version 08/05).
  • April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12). 

These dates are tentative and subject to change.  CMS will provide more information as it is available.

NUCC Transition Timeline

The NUCC approved at its in-person meeting on August 1, 2013 to align its transition timeline with Medicare's.  The timeline is:

  • January 6, 2014: Payers begin receiving and processing paper claims submitted on the revised 1500 Claim Form (version 02/12).
  • January 6 through March 31, 2014: Dual use period during which payers continue to receive and process paper claims submitted on the old 1500 Claim Form (version 08/05).
  • April 1, 2014: Payers receive and process paper claims submitted only on the revised 1500 Claim Form (version 02/12). 

FAQs

Check the NUCC’s FAQs for information about commonly asked questions about the 1500 Claim Form. The FAQs will be updated periodically.

Announcement

Here is the announcement of the final approval of the revised form.
• 02/12 1500 Claim Form Approval Announcement