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Last Modified: 9/3/2018 Location: FL, PR, USVI Business: Part B

CMS-1500 (02/12) paper claim form

Tired of paper?

Most claims for Medicare Part B services require electronic submission. For those instances where a paper claim is permissible, the CMS-1500 is available from several sources.
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. Health care professionals and suppliers are responsible for purchasing their own claim forms.
You can order the claim form from the United States Government Printing Office (GPO). Form CMS-1500 (02/12) is available in single, multipart snap-out sets or in continuous pin-feed formats. Contact the GPO at 1-866-512-1800 or visit http://bookstore.gpo.gov/agency/193 external link.
Form CMS-1500 (02/12) may also be obtained 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.
Background
The National Uniform Claim Committee (NUCC) revised the CMS-1500 claim form to align the paper claim form with changes in the 5010 837P and accommodate ICD-10 reporting needs. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised paper claim form, CMS-1500 (version 02/12), OMB control number 0938-1197. CMS adopted form CMS-1500 (02/12) effective with claims received on and after April 1, 2014. Click here for more information on the new form, including new features.
Note: No changes have occurred to the 5010 837P electronic format as a result of the paper form changes.

Requirements and tips for completing the CMS-1500 (02/12) paper claim form

Detailed information concerning completion of form CMS-1500 (02/12) including tips and tutorials may be found on the claims submission guidelines section of this website. In addition, claim completion FAQs are also available.

Submission information

View the links below for the mailing addresses for your location on where to submit paper claim forms:
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.