Approval of the 1500 Claim Form

July 21, 2006

The NUCC is pleased to release the revised version of the 1500 Health Insurance Claim Form (version 08/05) that accommodates the reporting of the National Provider Identifier (NPI). The Office of Management and Budget (OMB) has approved the 1500 Claim Form under OMB Number 0938-0999 with an initial expiration date of June 30, 2007. The Centers for Medicare & Medicaid Services (CMS) will begin the renewal process for the form in January 2007.

Here is the PDF of the revised 1500 form, including the template and grid versions:

• Claim Form

The form may not print to its exact specifications unless using a special printer programmed to print forms. Print specifications are available in Appendix A of the Reference Instruction Manual.

To receive copies of the revised form, please contact:

TFP Data Systems: or 800-482-9367 ext. 1770
Or
Your forms distributor

Arrangements are still being made with the Government Printing Office regarding their distribution of the revised form.

The following change log shows all changes between the 12/90 version and 08/05 version of the form.

• Modified Transition Timeline

The NUCC has made modifications to its recommended timeline for transitioning to the revised 1500 Claim Form. The timeline is now:

October 1, 2006
Health 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, 2007
The 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.