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Last Modified: 11/3/2017 Location: PR, USVI Business: Part B

Important instructions for completing paper claim form CMS-1500 (version 02/12)

Have you been impacted by a disaster in Puerto Rico or the U.S. Virgin Islands and are now submitting paper claims? If the paper claim form is not completed properly, First Coast Service Options (First Coast) will return the claim to you for correction. Before you complete the claim form, make sure to review these important tips to avoid the most common errors we see:
All paper claims are required to be submitted using an original red/white CMS-1500 (02/12) form. Black and white copies will be returned as unprocessable.
You can order the claim form from the United States Government Printing Office (GPO). Contact the GPO at 1-866-512-1800 or visit http://bookstore.gpo.gov/agency/193 external link. Health care professionals and suppliers are responsible for purchasing their own claim forms.
You can also obtain the form from printing companies and office supply stores as long as it follows CMS-approved specifications. These specifications may be found in the Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) Medicare Claims Processing Manual (Pub. 100-04, chapter 26, section 30) external pdf file on the CMS website.
When completing the claim form, ensure to use all capital typeface. This is especially important when indicating letters "I" and "L" in Item 24E.
Throughout the claim, use either six-digit dates of service (MM/DD/YY) or eight-digit dates of service (MM/DD/CCYY) -- be consistent.
Item 11 -- Ensure to complete Item 11 on all claims. View this brief animation for tips on completing Item 11 flash file. Note: Enter the word NONE if Medicare is the patient's primary insurance.
Item 12 -- Make sure your patient has signed Item 12 or include 'signature on file' in the space.
Item 14 -- Although space for a qualifier is included, Medicare does not use this information; do not enter a qualifier in item 14.
Item 17 -- If the item or service was ordered, supervised or referred by a physician, enter the name and qualifier of that referring, ordering or supervising physician in Item 17. Enter the qualifier to the left of the dotted vertical line on item 17.
The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
DN -- referring provider
DK -- ordering provider
DQ -- supervising provider
Item 17b -- Enter the national provider identifier (NPI) of the referring/ordering individual provider only.
Note: Claims submitted with an NPI and without one of the Item 17 qualifiers or an invalid qualifier will be returned as an unprocessable claim (RUC).
Item 21 -- When completing Item 21 pdf file, you may enter up to 12 diagnosis codes. Note: this information appears opposite lines with letters A-L. Relate lines A- L to lines of service in Item 24E by the letter of the line. Use the highest level of specificity.
Do not provide narrative description in this field.
Do not insert a period in the ICD-10-CM code.
Enter the ICD indicator 0 as a single digit between the vertical, dotted lines.
Item 32 -- Enter the name, address and ZIP of location where services were rendered for all locations. Click here for more information on Item 32.
You can find additional helpful information on completing the entire paper claim form here.

Important payment floor reminder

After a claim is approved for payment, there is a mandatory waiting period before payment funds or a check will be released. This is called the claim 'payment floor'.
If you submit claims on a paper form, you will have a mandatory 29-day payment floor. In other words, you will not have the funds released or a check cut for 29 days after the claim is approved to pay. This is longer than the 14-day payment floor for electronically submitted claims.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.