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Insurance Claim Forms

The revised CMS 1500 (08/05) Claim Form is now available.

The revised CMS1500 (08/05) claim form accommodates the reporting of the National Provider Identifier (NPI) number. The NPI must be used by all HIPAA covered entities, such as health plans, health care clearinghouses and health care providers.

The barcode has been removed on the revised CMS 1500 Form. Scanners can be programmed to read the 1500 symbol in black ink.

The recommended transition timeline is:

October 1, 2006: Health plans, clearing houses and other information support vendors should be ready to handle and accept the revised (08/05) 1500 Claim Form.

October 1, 2006 - March 31, 2007: Providers can use either the current (12/90) version or the revised (08/05) version of the 1500 Claim Form.

April 1, 2007: The current (12/90) version of the 1500 Claim Form is discontinued; only the revised (08/05) form is to be used. All rebilling of claims should use the revised (08/05) form from this date forward, even though earlier submissions may have been on the current (12/90) 1500 Claim Form.

A sample of the new form can be provided for your programming requirements.

New CMS Forms (Rev. 8/05)
Item No. Description # of Plies Qty/Ctn Price
WCMS-1500CS 8.5 x 11 Laser Sheet 1 2500 45.00
WCMS-15001 9.5 x 11 Pinfeed WH 1 2500 42.00
WCMS-15002 9.5 x 11 Pinfeed WH/CAN 2 1000 47.00
WCMS-15002W 9.5 x 11 Pinfeed WH/WH 2 1000 45.36
WCMS-1500U2 8.5 x 11.75 Snap Out WH/CAN 2 500 42.00


HCFA 1500 Claim Forms
Item No. Description # of Plies Qty/Ctn Price
WHCFA1500CS90 8 1/2 X 11 LASER SHEET w/bc 1 2500 51.84
WHCFA1500CSN90 8 1/2 X 11 LASER SHEET w/o/bc 1 2500 47.00
WHCFA1500190 9 1/2 X 11 PINFEED WH 1 2500 42.00
WHCFA1500290 9 1/2 X 11 PINFEED WH/CAN w/bc 2 1000 47.00
WHCFA15002N90 9 1/2 X 11 PINFEED WH/CAN w/o/bc 2 1000 47.00
WHCFA150090 9 1/2 X 11 PINFEED WH/WH w/bc 2 1000 47.00
WHCFA1500N90 9 1/2 X 11 PINFEED WH/WH w/o/bc 2 1000 47.00
WHCFA1500U290 8 1/2 X 11 3/4 SNAP OUT WH/CAN w/bc 2 500 42.00
         

A variety of efficiency enhancing formats are available:

  • Forms for laser printers
  • Peel-off address labels
  • Choice of white/canary copies
  • Black bar codes on all parts