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Beginning on April 1, 2014, the only paper version of the 1500 professional claim form that is accepted by the Centers for Medicare & Medicaid Services (CMS) is version 02-12. To be in line with CMS, Midlands Choice has also adopted this practice. Although the ICD-10 code implementation date has been postponed, the transition to the 1500 v. 02-12 form was implemented as scheduled.

All paper claims for professional services submitted to Midlands Choice must be on the 1500 version 02-12 claim form, regardless of the date of service on the claim.  Claims submitted on outdated versions of the form will be returned, requiring that the claim be resubmitted on the correct version of the form.

When submitting claims on the revised version of the claim form, it is imperative that the data entered be aligned to display in the correct fields. Some changes from the CMS 1500 version 08-05 include:

• Boxes 8, 9b, 9c, and 30 are now marked as “Reserved for NUCC Use” and should be left blank.
• Box 21 (Diagnosis or Nature of Illness or Injury) has spaces available for 12 diagnosis codes, which are designated by alpha characters.  In addition, the format of the codes is left to right.  Previously, box 21 had space for only 4 codes, designated numerically, and in a different formation.
• Box 24E (Diagnosis Pointer) must contain the alpha character(s) that corresponds to the diagnosis entered in box 21.

For more information on the 1500 v. 02-12 claim form, visit the National Uniform Claim Committee website at www.nucc.org.

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