Only the following providers and suppliers may submit paper claims, as mandated by HIPAA:
• Small providers who bill either Medicare Part A or B
o Part A – providers billing the fiscal intermediary with 25 or fewer full time employees or the equivalent
o Part B – providers billing the contractor with 10 or fewer full time employees or the equivalent.
• A dentist
• A participant in a Medicare Demonstration project where paper claims filing is required
• A provider that conducts mass immunizations
• Submits claims where one or more payer is responsible for payment prior to Medicare payment
• Provider is experiencing a disruption in electricity or communication connections beyond their control
• If the provider can establish an “unusual circumstance” exists that precludes submission of electronic claims Contractors may send requests to providers to validate their exception status. Providers not meeting one of
the exceptions must submit claims electronically.
Preparing the CMS-1500 Claim Form
The Form CMS-1500 (Health Insurance Claim Form) is the standard claim form used by a non-institutional provider or supplier to bill Medicare contractors and durable medical equipment contractors when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement
for electronic submission of claims.
The National Uniform Claim Committee (NUCC) is responsible for the maintenance of the form CMS-1500.
CMS and contractors do not provide the form to providers for claim submission. Forms may be purchased from the U.S. Government Printing Office at (866) 512-1800, local printing companies in your area and/or office supply stores. Each of these sources sells the health insurance claim form CMS-1500 in various configurations (single part, multi-part, continuous feed, laser, etc.)
NUCC revised the Form CMS-1500. The new version, Form CMS-1500 (08-05), replaced the CMS-1500 (12- 90) version. The 08-05 version of the CMS-1500 form was effective June 29, 2007. Medicare will reject any 12-90 version forms received.
The claim form must be:
• An original CMS-1500 printed in red “drop out “ ink with the printed information on back (photocopies are not acceptable);
• Size – 8½” x 11” with the printer pin-feed edges removed at the perforations;
• Free from crumples, tears, or excessive creases (to avoid this, submit claims in an envelope that is full letter size or larger);
• Thick enough (20-22 lbs.) to keep information on the back from showing through;
• Clean and free from stains, tear-off pad glue, notations, circles or scribbles, strike-overs, crossed-out information or white out.
Many institutions limit access to their online information. Making this information available will be an asset to all.