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CMS 1500 Health Insurance Claim Form_CMS 1500 Health Insuran
Updated:2011-12-31 Category:tops
Snapshot of the Word Document:CMS 1500 Health Insurance Claim Form.doc
CMS 1500 Health Insurance Claim Form

Revised Version 8/05

The National Uniform Claim Committee (NUCC) in conjunction with the Office of Management and Budget (OMB) has revised and approved significant changes to the existing CMS 1500 forms, version 12/90. These updates to the health insurance claim form dramatically affect our eleven TOPS skus.

Although these eleven items are to be discontinued on April 1, 2007, there is a transition period where these will still be made available for purchase. The transition period goes from October 1, 2006 until March 31, 2007.

50121 – HCFA Claim Form W/Bar 1 Part Continuous 3000/CT

50122 – HCFA Claim Form W/O Bar 1 Part Continuous

50123 – HCFA Claim Form W/Bar 2 Part Continuous

50124 – HCFA Claim Form W/O Bar 2 Part Continuous 1500/CT

50125– Laser HCFA With Bar 5 PK/500 – 2500/CT

50126 – Laser HCFA W/O Bar 5 PK/500 – 2500/CT

50127 – HCFA Claim Form W/Bar and Label 1 Part Continuous

50128 – HCFA Claim Form W/Bar and Label 2 Part Continuous

50129 – CMS/HCFA Claim Form W/Bar 2 Part Continuous, 100 Sets

50130 – HCFA Claim Form W/Bar 2 Part Continuous, 14”

50135 – Laser HCFA W/Bar 250/PK – 8PK/CT

The current TOPS items above will be replaced with the following 5 skus below, version 8/05. These items will be made available October 1, 2006 and will be required to be used April 1, 2007 when the old TOPS skus are discontinued. (Please note the “R” at the end of the item number will eventually be removed after the transition period is complete.)

50122R – CMS 1500 Claim Form, 1 Part Continuous

50124R – CMS 1500 Claim Form, 2 Part Continuous 1500/CT

50126R – CMS 1500 Claim Form, Laser, 5 PK/500 – 2500/CT

50129R – CMS 1500 Claim Form, 2 Part Continuous, 100 Sets

50135R – CMS 1500 Claim Form, Laser, 250/PK – 8PK/CT

Having both sets of items available on October 1, 2006 allows customers the flexibility to decide when they are going to make the transition from the old forms and software to the new, updated forms and software.

To reiterate, the key dates to remember are:

    October 1, 2006Health plans, clearinghouses, and other information support vendors should be ready to handle and accept the revised (08/05) 1500 Claim Form. October 1, 2006 - March 31, 2007 Providers can use either the current (12/90) version or the revised (08/05) version of the 1500 Claim Form. April 1, 2007The current (12/90) version of the 1500 Claim Form is discontinued; only the revised (08/05) form is to be used. All rebilling of claims should use the revised (08/05) form from this date forward, even though earlier submissions may have been on the current (12/90) 1500 Claim Form.

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    http://www.ussco.com/email/officeline/02_10_07/images/TOPSHealthInsuranceClaimForm.doc
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