1500 Claim Form

1500 Claim Form 02/12 Version

Use of the Version 02/12 1500 Claim Form went into effect April 1, 2014.

The following is the PDF of the revised 1500 form, including the template and grid versions: (The form image may not print to scale.  This image of the form should not be used for claims submission. This image should also not be used by forms printers to create the form.)

• 02/12 Claim Form

DO NOT email completed 1500 Claim Forms to the NUCC. The NUCC does not process claims. Send completed forms to the appropriate payer.

To receive copies of the 02/12 1500 Claim Form, contact:

• Your current forms supplier;
• ComplyRight: https://www.complyrightdealer.com/cms-1500-3; or
• The Government Printing Office: http://bookstore.gpo.gov/catalog/government-forms-phone-directories or 866-512-1800

02/12 1500 Form Change Log

The following change log shows all changes between the 08/05 version and 02/12 version of the form.

• 02/12 1500 Form Change Log

1500 Claim Form Change Requests

To request changes to the 1500 Claim Form layout, please complete the following form. The same form can be used to submit requests for changes to the NUCC 1500 Reference Instruction Manual.

• 1500 Form Change Request Form

Background Information

The NUCC replaced the Uniform Claim Form Task Force, which was co-chaired by the AMA and CMS and resulted in the development of the 1500 Claim Form, a single paper claim form for use by all third-party payers. With the transition of the medical community to electronic data interchange and the proliferation of data element definitions among various payers, it became essential that an organization be established to maintain uniformity and standardization in these areas. The NUCC is responsible for maintaining the integrity of the data sets and physical layout of the hard copy 1500 Claim Form.

From the provider viewpoint, non-uniform data elements have caused significant frustration, claims billing and processing delays, and rejections. From the payer viewpoint, claims that are not in the required format may be resubmitted several times before they can be processed. The result is a very labor-intensive and costly business practice for providers and payers.

Through an iterative process, the NUCC used existing implementation guides, data dictionaries and results from ongoing standardization efforts within the health care industry to consolidate the many current data sets into one set.  The NUCC continues to work to optimize, as necessary, coordination of implementation within the health care industry, working with ASC X12N as required, to resolve data maintenance and standards problems that arise from the NUCC's work.