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SAMPL E - NUCC

L E. P. AM. S. PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12). L E. P. AM. S. PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12). CARRIER. HEALTH INSURANCE CLAIM FORM. APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12. PICA PICA. 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S NUMBER (For Program in Item 1). HEALTH PLAN BLK LUNG. (Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) (ID#) (ID#) (ID#). 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial).

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE G. EPSDT Family Plan ID. QUAL. NPI NPI ( ) PLEASE PRINT OR TYPE QUAL. QUAL. R svd for N UC e A. E. I. B. F. J. C. G. K. D. L. H. ICD Ind. IL L N E S S , IN JU R Y o r P R E G N A N C Y (L M P ) (N U C C ) co m p le te ite m s 9 , 9 a a n d 9 d 0 2 /1 2 O T H E R

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National Uniform Claim Committee CMS-1500 Claim - nucc.org

www.nucc.org

National Uniform Claim Committee . 1500 Health Insurance Claim Form . Reference Instruction Manual . for Form Version 02/12 . July 2018 . Version 6.0 7/18

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National Uniform Claim Committee CMS-1500 Claim

www.nucc.org

The 1500 Health Insurance Claim Form (1500 Claim Form) answers th e needs of many health care payers. It is the basic paper claim form prescribed by many payers for claims submitted by physicians and suppliers, and in some cases, for am bulance services.

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National Uniform Claim Committee - nucc.org

www.nucc.org

Version 3.3 8/18 2 02/12 1500 Claim Form Map to the X12 837 Health Care Claim: Professional (837) The following is a crosswalk of the 02/12 version 1500 Health Care Claim Form (1500 Claim Form) to the

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National Uniform Claim Committee CMS-1500 Claim

www.nucc.org

The NUCC has developed this general instructions document for completing the 1500Claim Form. This document is intended to be a guide for completing the 1500 Claim Form and not definitive instructions for this purpose. Any user of this document should refer to the most current federal, state, or other payer instructions for specific

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National Uniform Claim Committee CMS-1500 Claim - NUCC

www.nucc.org

Any payer-specific instructions for completion of the 1500 Claim Form need to be maintained in a separate document. The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by the AMA or the NUCC. You should consult with an appropriate

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1500 Form Mapping to 837 Claim Transaction - NUCC

www.nucc.org

1500 Claim Form Map to the X12 837 Health Care Claim: Professional The following is a crosswalk of the 1500 Health Care Claim Form to the X12 837 Health Care Claim: Professional Version 4010A1 electronic transaction. This document is meant to be used in conjunction with the NUCC Data Set.

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