How to prepare CMS 1500 paper claim.

PREPARING THE CMS-1500 CLAIM FORM

The Form CMS-1500 (Health Insurance Claim Form) is the standard claim form used by a non-institutional provider or supplier to bill Medicare contractors and durable medical equipment contractors when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

The National Uniform Claim Committee (NUCC) is responsible for the maintenance of the form CMS-1500. CMS and contractors do not provide the form to providers for claim submission. Forms may be purchased from the U.S. Government Printing Office at (866) 512-1800, local printing companies in your area and/or office supply stores. Each of these sources sells the Health Insurance Claim Form CMS-1500 in various configurations (single part, multi-part, continuous feed, laser, etc.)

NUCC revised the Form CMS-1500. The new version, Form CMS-1500 (08-05) replaced the CMS-1500 (12- 90) version. The 08-05 version of the CMS-1500 form was effective June 29, 2007. Medicare will reject any 12-90 version forms received.


Intelligent Character Recognition (ICR)
NHIC is using an Intelligent Character Recognition (ICR) system to capture claims information directly from the CMS-1500 claim form.

ICR benefits include:
�� Greater efficiency;
�� Improved accuracy;
�� More control over the data input, and
�� Reduced data entry cost for the Medicare program.


The ICR is capable of going beyond simply scanning claims data into the computer and has a sophisticated computer “brain” which verifies claims information against several data files as well as performing various claims processing functions.

With the ICR system, it is important that claims be submitted with proper and legible coding. This is because the ICR output is largely dependent on the accuracy and legibility of the claim form submitted.


If you are not billing electronically, consider it! However, when you bill on paper, follow these tips when completing your CMS-1500 forms:

The font should be:

•  Legible (Change typewriter ribbon/PC printer cartridge frequently, if necessary. Laser printers are recommended)

•  In Black Ink

• Pica, Arial 10, 11 or 12 font type

• CAPITAL letters

The font must NOT have:

•  Broken characters

• Script, Italics or Stylized font

•  Red ink

•  Mini-font

•  Dot Matrix font

Do NOT bill with:

•  Liquid correction fluid changes.

• Data touching box edges or running outside of numbered boxes (left justify information in each box).

Exception: when using the 8-digit date format, information may be typed over the dotted lines shown in date fields, i.e., Item 24a.

•  More than six service lines per claim (use a new form for additional services);

•  Narrative descriptions of procedure, narrative description of modifier or narrative description of diagnosis (the CPT, Modifier or ICD-9-CM codes are sufficient);

•  Stickers or rubber stamps (such as “tracer,” “corrected billing,” provider name and address,

• NHIC’s address at top of the form;

•  Special characters (i.e., hyphens, periods, parentheses, dollar signs and ditto marks).

•  Handwritten descriptions;

•  Attachments smaller than 8 1/2 x 11.

The claim form must be:

•  An original CMS-1500 printed in red “drop out “ ink with the printed information on back (photocopies are not acceptable);

•  Size - 8½” x 11” with the printer pin-feed edges removed at the perforations;

•  Free from crumples, tears, or excessive creases (to avoid this, submit claims in an envelope that is full letter size or larger);
•  Thick enough (20-22 lbs.) to keep information on the back from showing through;

•  Clean and free from stains, tear-off pad glue, notations, circles or scribbles, strike-overs, crossed-out information or white out.

NOTE: The following examples are in black and white. An original CMS-1500 claim form is printed in red “drop out” ink with the printed information on the back.