SAMPL E - NUCC
APPROVED OMB-0938-1197 FORM 1500 (02-12) 1a. INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
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National Uniform Claim Committee CMS-1500 Claim
www.nucc.orgThe 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.
National Uniform Claim Committee CMS-1500 Claim - nucc.org
www.nucc.orgNational Uniform Claim Committee . 1500 Health Insurance Claim Form . Reference Instruction Manual . for Form Version 02/12 . July 2018 . Version 6.0 7/18
National Uniform Claim Committee - nucc.org
www.nucc.orgVersion 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
National Uniform Claim Committee CMS-1500 Claim
www.nucc.orgThe 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
1500 Form Mapping to 837 Claim Transaction - NUCC
www.nucc.org1500 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.
National Uniform Claim Committee CMS-1500 Claim - NUCC
www.nucc.orgAny 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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