CMS Pub. 100-04, ch. 26, § 10

The Administrative Simplification Compliance Act (ASCA) requires that Medicare

claims be sent electronically unless certain exceptions are met. Providers meeting an

ASCA exception may send their claims to Medicare on a paper claim form. (For more

information regarding ASCA exceptions, refer to Chapter 24.)

Providers sending professional and supplier claims to Medicare on paper must use Form

CMS-1500 in a valid version. This form is maintained by the National Uniform Claim

Committee (NUCC), an industry organization in which CMS participates. Any new

version of the form must be approved by the White House Office of Management and

Budget (OMB) before it can be used for submitting Medicare claims. When the NUCC

changes the form, CMS coordinates its review, any changes, and approval with the OMB.

The NUCC has recently changed the Form CMS-1500, and the revised form received

OMB approval on June 10, 2013. The revised form is version 02/12, OMB control

number 0938-1197.

The revised form will replace the previous version of the form 08/05, OMB control

number 0938-0999.

Throughout this chapter, the terms, “Form CMS-1500,” “Form 1500,” and “CMS-1500

claim form” may be used to describe this form depending upon the context and version.

The term, “CMS-1500 claim form” refers to the form generically, independent of a given

version.

Medicare will conduct a dual-use period during which providers can send Medicare

claims on either the old or the revised forms. When the dual-use period is over, Medicare

will accept paper claims on only the revised Form 1500, version 02/12.

For the implementation and dual-use dates, contractors shall consult the appropriate

implementation change requests for the revised Form 1500. Providers and other

interested parties may obtain the implementation dates on the CMS web site @

www.cms.gov.

Reminder: Regardless of the paper claim form version in effect: Providers cannot

submit ICD-10-CM codes for claims with dates of service prior to implementation of

ICD-10.

Medicare A/B MACS (B), DME MACS, physicians, and suppliers are responsible for

purchasing their own CMS-1500 claim forms. Forms can be obtained from printers or

printed in-house as long as they follow the specifications developed by the NUCC.

Photocopies of the CMS-1500 claim form are NOT acceptable. Medicare will accept any

type (i.e., single sheet, snap-out, continuous feed, etc.) of the CMS-1500 claim form for

processing. To purchase forms from the U.S. Government Printing Office, call (202)

512-1800.

The following instructions are required for a Medicare claim. They apply to both the

08/05 and 02/12 versions of the form except where noted. A/B MACs (B) and DME

MACs should provide information on completing the CMS-1500 claim form to all

physicians and suppliers in their area at least once a year.

These instructions represent the minimum requirements for using this form to submit a

Medicare claim. However, depending on a given Medicare policy, there may be other

data that should also be included on the CMS-1500 claim form; if so, these additional

requirements are addressed in the instructions you received for such policies (e.g., other

chapters of this manual).

Providers may use these instructions to complete this form. The CMS-1500 claim form

has space for physicians and suppliers to provide information on other health insurance.

This information can be used by A/B MACs (B) to determine whether the Medicare

patient has other coverage that must be billed prior to Medicare payment, or whether

there is another insurer to which Medicare can forward billing and payment data

following adjudication if the provider is a physician or supplier that participates in

Medicare. (See Pub. 100-05, Medicare Secondary Payer Manual, chapter 3, and chapter

28 of this manual).

Providers and suppliers must report 8-digit dates in all date of birth fields (items 3, 9b,

and 11a), and either 6-digit or 8-digit dates in all other date fields (items 11b, 12, 14, 16,

18, 19, 24a, and 31).

Providers and suppliers have the option of entering either a 6 or 8-digit date in items 11b,

14, 16, 18, 19, or 24a. However, if a provider of service or supplier chooses to enter 8-digit dates for items 11b, 14, 16, 18, 19, or 24a, he or she must enter 8-digit dates for all

these fields. For instance, a provider of service or supplier will not be permitted to enter

8-digit dates for items 11b, 14, 16, 18, 19 and a 6-digit date for item 24a. The same

applies to providers of service and suppliers who choose to submit 6-digit dates too.

Items 12 and 31 are exempt from this requirement.

Legend Description

MM Month (e.g., December = 12)

DD Day (e.g., Dec15 = 15)

YY 2 position Year (e.g., 1998 = 98)

CCYY 4 position Year (e.g., 1998 = 1998)

(MM | DD | YY) or (MM | DD | CCYY) A space must be reported between month,

day, and year (e.g., 12 | 15 | 98 or 12 | 15 |

1998). This space is delineated by a dotted

vertical line on the Form CMS-1500)

Legend Description

(MMDDYY) or (MMDDCCYY) No space must be reported between month,

day, and year (e.g., 121598 or 12151998).

The date must be recorded as one

continuous number.