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REVISED CMS 1500 PAPER CLAIM FORM: VERSION 02/12

February 16, 2014

CMS began receiving claims on the revised CMS 1500 claim form (02/12) on January 6, 2014. The CMS 1500 claim form is the required format for submitting professional and supplier claims to Medicare on paper, when submitting paper claims is permissible

Features of the Revised Form
The revised form, among other changes, notably adds the following functionality:

• Indicators for differentiating between ICD-9-CM and ICD-10-CM diagnosis codes.

• Expansion of the number of possible diagnosis codes to 12.

• Qualifiers to identify the following provider roles (on item 17):
o Ordering
o Referring
o Supervising

Note: although the revised CMS 1500 claim form has functionality for accepting ICD-10 codes, do not submit ICD-10 codes on claims for dates of service prior to October 1, 2014.

Instructions for Completing the Revised Form
Instructions for completing the revised CMS 1500 claim form (02/12) are provided in the Medicare Claims Processing Manual (Pub. 100-04).

Medicare will continue to accept the old CMS 1500 claim form (08/05) through March 31, 2014. However, on April 1, 2014, Medicare will receive professional and supplier paper claims on only the revised CMS 1500 claim form (02/12). Claims sent on the old CMS 1500 claim form (08/05) will not be accepted.

Note: The Administrative Simplification Compliance Act (ASCA) requires that Medicare claims be sent electronically unless certain exceptions are met. Some Medicare providers qualify for these exceptions and send their claims to Medicare on paper. For more information about ASCA exceptions, please contact the Medicare Administrative Contractor (MAC) who processes your claims. Claims sent electronically must abide by the standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The current standard adopted under HIPAA for electronically submitting professional health care claims is the 5010 version of the ASC X12 837 Professional Health Care Claim standard and its implementation specification, Technical Report 3 (TR3). More information about the ASC X12 and TR3 is available on the ASC X12 website.

REVISED CMS 1500 PAPER CLAIM FORM: VERSION 02/12


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