Last Modified: 11/3/2017 Location: FL, PR, USVI Business: Part B
CMS-1500 (02/12) paper claim form
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.
Health care professionals and suppliers are responsible for purchasing their own claim forms. Form CMS-1500 (02/12) is available in single, multipart snap-out sets or in continuous pin-feed formats and may be obtained from the United States Government Printing Office (GPO). Contact the GPO at 1-866-512-1800 or visit http://bookstore.gpo.gov/agency/193 . 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) on the CMS website.
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.
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.