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. 

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.

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. 

  • 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. 

Submission information

View our claims contact page for mailing addresses for your location on where to submit paper claim forms.