Insurance claim form 1500, also known as the CMS-1500 form, is a claim form that is used by a non-institutional provider when billing Medicare and durable medical equipment regional carriers. This form is needed when a waiver from the Administrative Simplification Compliance Act or ASCA has been granted to a provider, so that the provider does not have to submit claims electronically. The CMS-1500 claim form is also used to bill Medicaid state agencies.
Acquiring the Form
The CMS-1500 claim form is maintained by the National Uniform Claim Committee or NUCC. Purchase the form from the U.S. Government Printing Office, a local printing company in your area or any office supply store. The CMS-1500 claim form is available in many configurations, depending on your needs or type of printer. Use the newest version of the CMS-1500 claim form, which is dated 08-05. This version became effective on June 29, 2007. The old version of the form, dated 12-90, will be rejected by Medicare.
Form Completion Tips
Use Pica or Arial font at a size of 10, 11 or 12, and use capital letters and black ink. When entering information into the form, make sure not to have broken characters, use italics or any type of stylized font or red ink. The form should not be sent with liquid correction fluid; data should not touch the edges of boxes; and only use standard codes, not narrative descriptions. Only original forms can be sent, which means that you cannot send a photocopy of the form. Remove any perforations from the form so it conforms to the standard size of 8 ½" x 11".
Entering Information
Indicate at the top of the form whether it is being used for a Medicare, Medicaid or other type of claim submission. Enter the ID number of the patient, followed by the name, date of birth, sex and his complete address. If a patient's condition is related to employment, an auto accident or some other accident, that should also be indicated.
Enter information for a Medigap policy or for a supplemental insurance plan in item No. 9. Only complete this section if you are a participating physician or supplier and have agreed to accept Medicare payments or if a patient agrees to assign benefits under a Medigap policy. Each section of the form should be completed depending on where the claim form is being submitted such as Medicare or a Medicaid state agency.
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