1500 Health Insurance Claim Form

1500 Health Insurance Claim Form

In 2013 and 2014 there will be many changes in the healthcare field. Some of the changes include mandatory reporting of PQRS, Affordable Care Act, ICD-10 CM diagnosis codes, and the new 1500 Health Insurance Claim Form. My articles over the next year will concentrate on these changes and how they affect chiropractic physicians. In this article, I am going to answer questions pertaining to the new 1500 HealthInsurance Claim Form.

In June of 2013, the National Uniform Claim Committee (NUCC) announces the final approval of the Version 2/12 1500 Heal Insurance ClaimForm (1500 Claim Form). The new 1500 claim numerous changes that are important for doctors and their staff to understand.

1.Why is a new claim form needed?

A new claim form is needed to accommodate the reporting needs of the ICS-10 CM diagnosis codes that will go into effect in October 2014. In addition, the new form complies with the Accredited Standards Committee requirements for the X12 837 Health Care Claim: Professional Version 5010/5010A1 electronic form.

2. What is the conversion timeline for the new 02/12 1500 Health Insurance Claim Form?

The CMS’s tentative implementation timeline for the new claim form is as follows:

January 6, 2014Medicare begins receiving and processing claims submitted on the revised 1500 Claim Form Version 02/12 and the revised electronic form
January 6, 2014- March 31, 2014Medicare will continue to receive and process claims submitted on the old 08/05 1500 claim form and the new 02/12 claim form as well as the old and new electronic forms
April 1, 2014Medicare receives and processes paper claims submitted only on the revised 02/12 1500 ClaimForm and the revised electronic form

Most third-party payers will follow Medicare’s implementation timeline for the new 1500 Claim Form. However, it is important to check with the payers with which you are contracted, as well as, any clearinghouse you may use to determine when they will be accepting the revised form.

3. Which changes on the form have the biggest impact on practitioners?

Item 21: Has an indicator (ICD Ind.) spot in the upper right-hand corner to identify which ICD code version (ICD-9 or ICD-10) is being reported.

Item 21: The number of diagnosis codes a practitioner is allowed to report has been increased from 4 diagnosis codes on the 08/05 1500claim form to 12 diagnosis codes on the revised 02/12 1500 Claim Form.

4. What changes have been made on the revised 02/12 1500 Claim Form?

LocationChange
  Header1. The 1500 rectangle symbol found on the 08/05 version was eliminated and replaced with a black and white two-dimensional QR (Quick Response) code on the 02/12 version. 
2. (NUCC) has been added after “APPROVED BY THE NATIONAL UNIFORM CLAIM COMMITTEE” 
3. 08/05 has been replaced by 02/12 
Item 11. Changed “TRICARE CHAMPAS” and (sponsor’s SSN) on the 08/05
version to “TRICARE” and
(ID #/DoD#) respectively on the
02/12 version.
 2. Changed (SSN or ID) under “GROUP HEALTH PLAN” on the 08/05
version to (ID#) on the 02/12
version. 
3. Changed (SSN) under “FECA BLK LUNG” on the 08/05 version to (ID#) on the 02/12 version. 
4. Changed (ID) under “OTHER” on the 08/05 version to (ID#) on the 02/12 version.
Item 8Deleted “PATIENT STATUS” and all
content on the 08/05 version and changed the title to “RESERVED FOR
NUCC USE” on the 02/12 version.
Item 9bEliminated “OTHER INSURED’S DATE OF BIRTH” on the 08/05 version and replaced it with “RESERVED FOR NUCC USE” on the 02/12 version.
Item 9cDeleted “EMPLOYERS NAME OR
SCHOOL” on the 08/05 version and replaced it with “RESERVED FOR
NUCC USE” on the 02/12 version.
Item 10dChanged title from “RESERVED FOR LOCAL USE” on the 08/05 version to “CLAIMS Codes (Designated by
NUCC).”
Item 11bEliminated “EMPLOYERS NAME OR SCHOOL” on the 08/05 version and replaced the title to “OTHER CLAIM ID (Designated by NUCC)” on the 02/12 version. An added dotted line in the left-hand side of the field can accommodate a 2-byte qualifier
Item 11dChanged “if yes, return to and complete Item 9a-d” on the 08/05 version to “if yes, complete items 9, 9a, and 9d” on the 02/12 version
Item 14Changed title to “DATE OF CURRENT ILLNESS, INJURY, or Pregnancy
(LMP) on the 02/12 version with an added “QUAL” with a dotted line that can accommodate a 3-byte qualifier. The arrow on the 08/05 version was eliminated on the new
version.
Item 15Changed title from “IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE” on the 08/05 version to “OTHER DATE.” Added “QUAL.” With two dotted lines to accommodate a 3-byte qualifier on the 02/12 version.
Item 17A dotted line is added in the left-hand side of the field to accommodate a 2-byte qualifier on the 02/12
version.
Item 19Removed title “RESERVED FOR LOCAL USE” on the 08/05 version and added “ADDITIONAL CLAIM INFORMATION (Designated by NUCC)” on the 02/12 version.
Item 211. Changed instruction after title from “(Relate Items 1,2,3 or 4 to Item 24E by Line)” on the 08/05 version to ” Relate A-L to service line below (24E)” on the 02/12 version. 
2. An arrow pointing to 24E is removed on the 02/12 version.
3. “ICD Ind.” and two dotted lines in the upper right-hand corner of the field to accommodate a 1-byte indicator added to the 02/12 version. 
4. 8 additional lines added on the 02/12 version for diagnosis codes. 
5. Changed labels of the diagnosis code lines on the 08/05 version to alpha characters (A-L) on the 02/12 version. 
6. Removed the period in the diagnosis code lines in the 08/05 version.
Item 22Removed title “MEDICAID RESUBMISSION” on the 08/05 version and replaced it with “RESUBMISSION” on the 02/12 version.
Item 30Removed “BALANCED DUE” on the 08/05 version and replaced the title to “Rsvd for NUCC Use” on the 02/12 version.
FooterRemoved “APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)” and added, “APPROVED OMB-0938-1197 FORM 1500 (02/12).”
BackLanguage updates

5. What are the qualifiers used in Item 14?

Item 14 is used to report the 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY) date of the first date of the present injury (or illness) or pregnancy (use the date of the last menstrual period as the first date).

Enter the applicable qualifier to identify which date is being reported:

431 Onset of Current Symptoms or Illness

484 Last Menstrual Period

Enter the qualifier to the right of the vertical, dotted line.

6. What are the qualifiers used in Item 15, OTHER DATE?

Item 15 is used to enter another date related to the patient’s condition or treatment. Report date as a 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY).

The following qualifiers are applied to identify which date is being reported

454 Initial Treatment

304 Latest Visit or Consultation

453 Acute Manifestation of a Chronic Condition

439 Accident

455 Last X-ray

471 Prescription

090 Report Start (Assumed Care Date)

091 Report End (Relinquish Care Date)

444 First Visit or Consultation

Enter the qualifier between the left-hand set of vertical, dotted lines.

7. What are the qualifiers to identify the referring physician or other sources in item 17?

DN Referring Provider

DK Ordering Provider

DQ Supervising Provider

Enter the qualifier to the left of the vertical, dotted line.

8. What is item 19 used for on the new 1500 claim form?

This is used to list identifiers that may be required by some public and private payers. The identifiers in this section are too numerous to list. They can be found on the NUCC website at www.nucc.org.

9. What are the ICD indicators to identify which version of ICD codes are being reported in item 21?

9 ICD-9-CM

0 ICD-10-CM

Enter the ICD indicator to identify which version of ICD codes is being used. Enter the indicator between the vertical, dotted lines in the upper right-hand corner of box 21.

10. What are the ICD indicators to identify resubmission and/or original reference number in item 22?

7 Replacement of prior claim

8 Void/cancel of prior claim

When resubmitting a claim list the original reference number in box 22 with the appropriate resubmission code.

Providers can access the full Updates to 02/12 1500 Instruction Manual by visiting www.nucc.org. Additionally, chiropractic physicians may also access the 02/12 1500 Claim Form Map to the X12 Health Care Claim go to NUCC 1500 – 837P Crosswalk at www.nucc.org

Sources: National Uniform Claim Committee website at www.nucc.org: Updates to 02/12 1500 Instruction Manuals, NUCC Approves Transition Timeline for 02/12 1500 Form, 1500 Claim Form Reference Instruction Manual• Version 9.0 7/13, 02/12 1500 Claim Form• 02/12 1500 Form Change Log, 1500 Instructions ChangeLog, and NUCC 1500 – 837P Crosswalk.

About Author

ICS Staff

The Illinois Chiropractic Society staff works collaboratively on many topics to bring the most comprehensive and relevant information to our members. We have over 60 years of chiropractic experience and understand the heartbeat of the profession. We all look forward to providing relevant information to our members for years to come.

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