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02/12 1500 Claim Form

The Version 02/12 1500 Health Insurance Claim Form (02/12 1500 Claim Form) has received final approval by the Centers for Medicare & Medicaid Services (CMS) and the Office of Management and Budget (OMB). The revised form 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.

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

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

02/12 1500 Instructions

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 a complete list of changes that have been made to the Version 1.1 06/13 02/12 1500 instruction manual since its release in June 2013 and will be included in the next published version of the manual.
• 052014 02/12 1500 Instructions Change Log

02/12 1500 Form to 837P Map

The following is the Version 3.2 NUCC 1500 Claim Form Map to X12 Health Care Claim: Professional (837P) transaction, which was updated in April 2014:
• 02/12 1500 Claim Form Map to X12 837P

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).

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).

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

 

Copyright 2014 American Medical Association
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