Medicare will begin accepting claims on the revised form, 0212, on january 6, 2014. Dualuse period during which private insurance carriers and medicare continue to receive and process paper claims submitted on either version of the form. The revised cms1500 0805 replaces the current cms1500 1290. Updated december 2014 guide to cms1500 form 0805 box field name entering data in kareo current illness first symptom or injury accident or pregnancy lmp if applicable, select one of the following date types from the date type dropdown list under the condition tab. New hcfa form 2014 version 0212 of cms1500 for icd10. The format chosen must be consistent throughout these items. It is 100% compliant and printed to exact specifications. Starting april 1, 2014 only the revised, 0212 version will be accepted. Free fillable cms medical claim form 1500 template with. If the user would like to complete the form online, simply download, click inside. Download the form below and open the pdf using the acrobat reader software. The only acceptable claim forms are those printed in flint ocr red, j6983, or exact match ink. For this version of the forms, once you fill in the form, click the im finished. All cms1500 submissions whether submitted through an xml submission partner or sent directly to the board require a medical narrative andor attachment.
Download the fillable hcfa 1500 claim form that is both a fillable andor printable medical claim form that will provide insurance, illness and injury information for medical services claims. Government printing office, and local print companies throughout the country. Printed in red ink on special bond paper in strict compliance with nucc and cms regulations and specifications. Cms 1500 claim filing instructions locator type of health. The revisions, which better align the cms1500 with certain changes in the electronic health care claims, are. Payers receive and process claims submitted only on the revised cms1500 o the revised cms1500 0212 form is not required until april 1, 2014 the dates are based on the date the claim is mailedreceived by the payer where to obtain claim forms genius solutions will be selling the revised cms1500 0212.
The national uniform claim committee nucc maintains the cms1500 paper claim form and makes updates according to health care industry requirements. Thank you for helping us to process your claims efficiently and accurately. The cms 1500 claim form has been revised for effective date of use on january 6, 2014 tentative. All providers and health care professional can submit their with using old claim form cms1500 version 0805 till 31st march, 2014. This form will replace the current form cms1500, 08 05, effective with claims received on and after april 1, 2014.
The following instructions explain how to complete the cms 1500 claim. The current version of the instructions for the 0212 1500 claim form was released in. Authority to collect information is in section 205a, 1862, 1872 and 1874 of the social security act as amended, 42 cfr 411. A federal government website managed and paid for by the u. On or after april 1, 2014, claims that are submitted on a cms1500 version 0805 paper claim form will be returned to the provider. Fieldbyfield instructions for completing the cms1500 claim form are in the cms1500 completion section cms comp of the appropriate part 2 provider manual. Medicare will continue to accept claims on the old form, 0805, through march 31, 2014. We are authorized by cms, champus and owcp to ask you for information needed in the administration of the medicare, champus, feca, and black lung programs. Forprofit providers must include gross receipts tax in the total charges entered on each service line. Updated december 2014 guide to cms1500 form 0212 box field name entering data in kareo services record.
Genius solutions will be selling the new cms1500 0212 form. Beginning april 1, 2014, only version 0212 will be accepted. Make sure this fits by entering your model number approved cms1500 form 0212 to replace the previous cms form 0805 fully updated with the latest revisions, the new cms1500 form is 100% compliant and printed to exact specifications for layout, paper and ink. The bar code has been dropped from all versions of the form. Cms 1500 claim form gets an update the national uniform claim committee has updated the cms1500 insurance claim form to accommodate the new icd10 codes and current standard for electronic health.
Providers and suppliers have the option of entering either a 6 or 8digit date in items 11b, 14, 16, 18, 19, or 24a. Intermixing the two formats on the claim is not allowed. If using the cms 1500 0212, please continue to enter information in fields as instructed below. Cms 1500 federal tax id box 25 federal tax id number and type. The purpose of this manual is to help standardize nationally the manner in which the form is being completed. There will be a dualuse period when both forms can be used between january 6th and march 31st 2014. The cms 1500 form is a claim form used by health care providers to file for payment of medicare and medicaid claims. The revised cms1500 0212 replaced the former cms1500 08 05. On and after april 1, 2014, medicare will no longer accept claims on the old form cms1500, 0805. Anything submitted in boxes other than ad on the cms. Updated cms1500 claim form to be accepted beginning. Important revisions to the 1500 claim form the revised 1500 claim form expands the length of some existing fields, incorporates several new fields, and accommodates.
Note that you must click the hospital dates checkbox on the encounter record in order to enter the hospital dates. The current version of the original manual from the national uniform claim comettee of how to complete the cms1500 claim form. If you are submitting the cms1500 to replace a claim submitted previously. Please submit complete number including alpha prefix. The national uniform claim committee nucc has released a revised 1500 claim form, which is commonly referred to as the cms1500. On april 1, 2014, medicare will accept paper claims on only the revised cms 1500 claim form, 0212. Cms 1500 free download, create, edit, fill and print pdf. Enter the number issued for the practice by the internal revenue service. To print cms 1500 claim form, you will need a copy of adobe acrobat reader, which you can download for free right here. Services provided before oct 1, 2014, must use icd9cm diagnosis and inpatient procedure codes. Current and revised 1500 claim forms and instructions.
Our free fillable cms 1500 form pdf is a resource you can keep on hand for repeated use. Enter the tax id number and mark the box labeled ein. Smart forms cms 1500 software claim form softwarehcfa. Private insurance carriers and medicare begin receiving and processing paper claims submitted on the revised cms1500 claim form 0212. Cms 1500 instructions the following sections must be completed correctly or the bill will be returned and payment may be delayed or rejected. Clinical social workers may submit claims on the old cms1500 form, version, 0805, or the revised cms1500 form, version 0212.
The nucc has developed a 1500 reference instruction manual detailing how to complete the claim form. April 1, 2014, deadline for new cms 1500 claim form. Paper cms1500 requirements ms excel cms1500 examples paper. Cms 1500 claim filing instructions field locator requirements field description 1 not required type of health insurance coverage applicable to claim patients type of coverage. File claims with complete confidence the tfpsupported cms1500 offers some distinct advantages for healthcare customers. Department of health and human services centers for. Health insurance claim forms cms1500 2part snapout. The form will say 0212 in the lower right, replacing the current 0805 version. The form is published by the centers for medicare and medicaid services. The cms 1500 form is only filed by health care providers or medical suppliers, not by patients. The testing phase or transition of new claim form has already begun, medicare and other payers have started accepting claims filled on new revised cms1500 form version 0212 from 6th january, 2014.
Claim committees 1500 claim form instruction manual at blue cross and blue shield of oklahoma offers this guide to help you complete the cms1500 0212 form for your patients with blueshield coverage. The national uniform claims committee nucc has approved a transition timeline for the version 0212 1500 health insurance claim form 1500 claim form. The cms 1500 claim form is readily available from office supply stores, the u. Smart forms cms 1500 software is used as a claim form software to easily generate printing and electronic submission with tracking until payment. See black lung and feca instructions regarding required procedure and. Therefore, if a supplier travels less than 1 mile during a covered trip, the supplier would enter 1 unit on the claim form with the appropriate hcpcs code for mileage. Use of the revised form was required as of april 1, 2014. Authority to collect information is in section 205a, 1862, 1872 and 1874 of the social security act as. Clinical social workers should submit claims only on the revised cms1500 form, version 0212. The format of cms 1500 claim form is available in single, multiple, laser, continuous feed and other options for your choice, totally depending on the printer you are using and your.
Tmhp will accept both version 0805 and the new version 0212 of the cms1500 paper claim form until march 31, 2014. These are revised cms1500 0212 forms, and are mandatory for all claims filed on or after april 1, 2014. Free fillable cms 1500 template and information blue. On june 10, 20, the white house office of management and budget omb approved the revised form, 0212. Effective october 1, 2006, we will accept both current and revised 1500 claim forms. Cms 1500 federal tax id box 25 cms 1500 claim form. Cms1500 form blue cross and blue shield of oklahoma offers this guide to help you complete the cms1500 0805 form for your patients with blue shield coverage.