New 1500 Health Insurance Claim Form v. 02/12

Final Approval of the New 1500 Health Insurance Claim Form v.02/12

The NUCC and the Centers for Medicare & Medicaid Services (CMS) have approved the new 1500 Health Insurance Claim Form, along with a timeline for implementation:

• 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).

Two priorities that were included in the revisions to the 1500 Claim Form were 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 and the need to expand the number of diagnosis codes that can be reported in Item Number 21. The number that can be reported were increased from 4 to 12. Additional revisions 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.

The final 02/12 Version of the 1500 Health Insurance Claim Form (1500 Claim Form) accommodates reporting needs for ICD-10 and aligns with requirements of the Accredited Standards Committee.

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: 1500form@tfpdata.com 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

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