MEMORANDUM

DATE: February 5, 2014

TO: Participating Providers

FROM: Network Management Services

RE: CMS 1500 Form Version 02/2012 Mandated as of April 1, 2014

Dear Participating Provider,

We are pleased to announce that as of January, 6th 2014, we may accept the new CMS 1500 Claim Form,

Version 02/2012 in preparation for the upcoming transition to ICD-10. This form contains many exciting

enhancements from previous versions, which include:

Submission of up to 12 diagnosis codes on a single claim form, compared to only 4 on

previous versions

ICD-10 code friendly, in time for CMS October 1, 2014 deadline

We have included to this memo a copy of the new form. For a full list of enhancements, a copy of this

memo, and other useful aids, please visit our Provider Portal at www.mypreferredprovider.com and

access the Quick Link listed below:

New CMS 1500 Form Version 02/2012

Please note that starting April 1, 2014, this form will be a mandatory requirement set by CMS in order to

submit paper claims. If you are currently submitting claims to Preferred Care Partners, electronically,

please continue to do so. Preferred Care Partners continues to offer electronic claim submissions

through Availity, at no additional cost to you. You may register directly at www.Availity.com.

If you have any questions, please contact our Network Management Services Department at (877) 670-

8432. You may also email any questions to NMS@mypreferredcare.com.

Sincerely,

Network Management Services Department

Doc#: PCP00003_20140205

http://www.availity.com/mailto:NMS@mypreferredcare.comhttp:www.mypreferredprovider.com

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PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)

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PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)

HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12

PICA

1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER HEALTH PLAN BLK LUNG

(Medicaid#) e ber ID#) (ID#) (ID#) (ID#)(Medicare#) (ID#/Do D# ) (M m

3. PATIENTS BIRTH DATE SEX MM DD YY

M

2. PATIENTS NAME (Last Name, First Name, Middle Initial)

F

5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED

Self Child Other

CITY STATE

Spouse

8. RESERVED FOR NUCC USE

ZIP CODE TELEPHONE (Include Area Code)

( ) 9. OTHER INSUREDS NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous) a. OTHER INSUREDS POLICY OR GROUP NUMBER

NOYES

b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State)

YES NO

c. RESERVED FOR NUCC USE c. OTHER ACCIDENT?

YES NO

d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC)

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other information necessary

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

SIGNED DATE

15. OTHER DATE MM DD YY

14. DATE OF CURRENT ILLNESS, INJURY or PREGNANCY (LMP)MM DD YY

QUAL.QUAL.

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

17b. NPI

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) ICD Ind.

A. B. C. D.

E. F. G. H.

I. J. K. L. B. E.

From To D. PROCEDURES, SERVICES, OR SUPPLIESC.24. A. DATE(S) OF SERVICE

DIAGNOSIS MM DD YY MM DD YY

PLACE OF (Explain Unusual Circumstances) CPT/HCPCS MODIFIEREMG POINTERSERVICE

1

2

3

4

5

6 27. ACCEPT ASSIGNMENT? 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO.

(For govt. claims, see back)

YES NO

31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.)

a. b.NPISIGNED DATE NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE

PICA

1a. INSUREDS I.D. NUMBER (For Program in Item 1)

4. INSUREDS NAME (Last Name, First Name, Middle Initial)

7. INSUREDS ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

( ) 11. INSUREDS POLICY GROUP OR FECA NUMBER

a. INSUREDS DATE OF BIRTH SEX MM DD YY

M F

b. OTHER CLAIM ID (Designated by NUCC)

c. INSURANCE PLAN NAME OR PROGRAM NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

YES NO If yes, complete items 9, 9a and 9d.

13. INSUREDS OR AUTHORIZED PERSONS SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.

SIGNED

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY

FROM TO

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY

FROM TO

20. OUTSIDE LAB? $ CHARGES

YES NO

22. RESUBMISSION CODE ORIGINAL REF. NO.

23. PRIOR AUTHORIZATION NUMBER

F. H. I. J. DAYS EPSDT

G. RENDERINGID.Family

$ CHARGES OR

PROVIDER ID. #Plan QUAL.UNITS

NPI

NPI

NPI

NPI

NPI

NPI

28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd for NUCC Use

$ $

33. BILLING PROVIDER INFO & PH # ( )

a. b.NPIAPPROVED OMB-0938-1197 FORM 1500 (02-12)

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http:www.nucc.org

The 02/12 1500 Claim Form: Understanding the Changes to the Form

Common Myth The 1500 claim form (AKA HCFA 1500 or CMS

1500) is developed by the federal government.

False. The 1500 claim form is developed and maintained

by the NUCC. The form is in the public domain. The form is used by federal payer programs, e.g.,

Medicare, TRICARE, Black Lung, etc.

National Uniform Claim Committee The NUCC was formed in 1995 taking over for the

Uniform Claim Form Task Force that initially

developed the standard professional claim form

NUCC assumed responsibility for the development

and maintenance of the 1500 claim form

Its members represent a broad base of payers,

providers, standards developers, data content committees, public health organizations, and

vendors

The AMA is the Secretariat of the NUCC NUCCs Web site: www.nucc.org

http://www.nucc.org/

1500 Claim Form Revision Work Goal: Align the 1500 with changes in the 5010 837P

and accommodate ICD-10 reporting needs Work started in 2009 Reviewed existing data and needs for new Held a public comment period in October 2009 Defined the scope of the work to not change the

existing look of the form or underlying layout Made changes and mock-up of the form Held a public comment period in June 2011 on

proposed changes Completed final draft of form

1500 Claim Form Approval Updated form approved by NUCC in February 2012

(version 02/12) NUCC submitted updated form to CMS for approval CMS held a public comment period June 2012 OMB held a public comment period October 2012 NUCC received word of final approval in June 2013

Form Changes Header

Replaced 1500 rectangular symbol with black and white two-dimensional QR Code (Quick Response Code) Changed symbol to give visual difference for 02/12

form Changed 08/05 to 02/12

Form Changes 1

Changed TRICARE CHAMPUS to TRICARE Replaced SSN with ID#

Form Changes 8

Deleted PATIENT STATUS and content of field PATIENT STATUS is not reported in 837P so not

needed on the 1500 Changed title to RESERVED FOR NUCC USE

Form Changes 9b

Deleted OTHER INSUREDS DATE OF BIRTH, SEX OTHER INSUREDS DATE OF BIRTH, SEX is not

reported in 837P so not needed on the 1500 Changed title to RESERVED FOR NUCC USE

Form Changes 9c

Deleted EMPLOYERS NAME OR SCHOOL EMPLOYERS NAME OR SCHOOL not reported in

837P so not needed on 1500 Changed title to RESERVED FOR NUCC USE

Form Changes 10d

Changed title from RESERVED FOR LOCAL USE to CLAIM CODES (Designated by NUCC) Title changed to reflect usage of field

Form Changes 11b

Deleted EMPLOYERS NAME OR SCHOOL EMPLOYERS NAME OR SCHOOL not reported in 837P so not

needed on 1500 Changed title to OTHER CLAIM ID (Designated by

NUCC) Added dotted line in the left-hand side of the field to

accommodate a 2-byte qualifier Valid qualifiers are provided in the 02/12 Instruction Manual

Form Changes 14

Changed title to DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)

Removed the arrow and text in the right-hand side of the field

Added QUAL. with a dotted line to accommodate a 3byte qualifier Valid qualifiers are provided in the 02/12 Instruction Manual

Form Changes 15

Changed title from IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE to OTHER DATE

Added QUAL. with two dotted lines to accommodate a 3-byte qualifier Valid qualifiers are provided in the 02/12 Instruction Manual

Form Changes 17

Added a dotted line in the left-hand side of the field to accommodate a 2-byte qualifier Valid qualifiers are provided in the 02/12 Instruction

Manual

Form Changes 19

Changed title from RESERVED FOR LOCAL USE to ADDITIONAL CLAIM INFORMATION (Designated by NUCC) Title changed to reflect usage of field

Form Changes 21

Added ICD Ind. and two dotted lines to accommodate a 1-byte indicator Indicators provided in the 02/12 Instruction Manual

Added 8 additional lines for diagnosis codes Changed labels of the diagnosis code lines to alpha

characters (A L) Removed the period within the diagnosis code lines

Form Changes 22

Changed title from MEDICAID RESUBMISSION to RESUBMISSION. Title changed to reflect usage of field

Form Changes 30

Deleted BALANCE DUE. Changed title to Rsvd for NUCC Use. BALANCE DUE is not reported in 837P so not

needed on 1500

Transitioning to the Updated Form The NUCC approved the following transition timeline: 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).

This timeline aligns with Medicare's transition timeline.

What Users of the 1500 Need to Do

Talk to your practice management system vendor about upgrades to your system for the form

Use up your stock of 08/05 forms Order 02/12 forms Talk to your current forms vendor

Look at any payer-specific instructions you receive

NUCC Resources Materials located under the 1500 Claim Form tab:

NUCC Website: www.nucc.org Materials under the 1500 Claim Form tab on the

02/12 1500 Claim Form page The following resources are available: Sample 02/12 1500 Claim Form Change log of differences between the 08/05 and the

02/12 version NUCC instruction manual and change log 02/12 1500 Claim Form Map to the ASC X12 837P Frequently Asked Questions

http://www.nucc.org/

PCP00003 ICD-10 Memo-FINALCMS 1500 -- New Formunderstanding_the_changes_to_the_0212_1500_claim_form[1]The 02/12 1500 Claim Form: Understanding the Changes to the FormCommon MythNational Uniform Claim Committee1500 Claim Form Revision Work1500 Claim Form ApprovalSlide Number 6Form Changes Header Form Changes 1 Form Changes 8 Form Changes 9b Form Changes 9cForm Changes 10dForm Changes 11bForm Changes 14 Form Changes 15 Form Changes 17 Form Changes 19 Form Changes 21 Form Changes 22 Form Changes 30 Transitioning to the Updated FormWhat Users of the 1500 Need to DoNUCC Resources