Commonly asked questions about the 1500 Claim Form.
The 1500 Health Insurance Claim Form is a solution to the needs of many health payers. Back in the 1960s, there were a number of different claim forms and coding systems required by third-party payers to communicate information regarding procedures and services provided in a healthcare setting. But there was no standard.
Therefore, the American Medical Association joined forces with the Health Care Finance Administration (now the Centers for Medicare and Medicaid Services [CMS]) and other payer organizations to create the Uniform Claim Form Task Force in the 1980s. Their mission: to create and promote the use of a universal health claim form.
In the 1990s, the Uniform Claim Form Task Force was replaced by the National Uniform Claim Committee (NUCC), whose goal was to develop the standardized data set doctors use for electronic claims. Many providers now submit electronically, but software systems still depend on the paper 1500 Claim Form in its current image.
In 1996, HIPAA officially named the NUCC as an authoritative voice regarding content and data definitions for Electronic Data Interchange (EDI), as the committee members include payers as well as providers. The answers to the questions below are taken primarily from official NUCC and Medicare guidelines for the 02/12 1500 Claim Form, but note that some private payers may have different or tailored requirements.
Why was the 1500 Claim Form changed?
The most recent version of the form (02/12) was revised in preparation for the transition to ICD-10 coding, and to align the paper format with the 5010 837P electronic version. The latest adaptation was approved by the NUCC in February 2012, and the Office of Management and Budget in June 2013. It has been the required form for billing CMS since April 1, 2014; however, some private payers allowed the older version of the form (08/05) through October 1, 2014.
Can you have information preprinted on your claim forms?
Check with your payers to be sure that they will accept forms with preprinted information. In some cases, it may be acceptable to preprint sections such as “Billing Provider Information,” which remains the same regardless of the payer.
What about font size and punctuation?
The recommended font size is 10. Do not use commas, periods, or other symbols in the address field. A hyphen, however, should be used in the nine-digit ZIP code, and commas should be used to separate first, middle, and last names. Birth dates should be reported with eight digits, and other dates can be six or eight digits.
What is the symbol at the top of the 1500 Claim Form?
It is a Quick Response (QR) code. If scanned with a smartphone, it directs a Web browser to nucc.org, where you can review official instructions and updates.
What happened to items 8, 9b, 9c, 11b, and 30?
The data in these fields are not reported electronically in the 5010 837P form, and the paper form was changed to align better with the electronic format.
Why was 10d changed from “Reserved for Local Use” to “Claim Codes”?
This space is for the healthcare industry to ask the NUCC to create special codes for reporting, e.g., “condition codes.” It will likely be blank for most chiropractors.
Why did 11b change from “Employer’s Name or School Name” to “Other Claim ID”?
In response to input from users, this field was changed to accommodate information for property or casualty claim numbers. A two-digit qualifier such as “Y4” can be listed to indicate “Property Casualty Claim Number.”
Do chiropractors need to worry about the qualifier for item 14?
This three-digit qualifier indicates which date is being reported. For chiropractors the relevant option is “431,” which means “Onset of Current Symptoms or Illness.” Medicare does not require the use of this qualifier, but it may be wise to list it on all other claims. Check with each payer to be certain.
Why was item 15 changed to “Other Date”?
This block is not required by insurers at this time, but it may be useful to report other dates relevant to patient treatment. The qualifiers include (but are not limited to):
- 454 Initial Treatment
- 304 Last Visit or Consultation
- 453 Acute Manifestation of a Chronic Condition
- 439 Accident
- 455 Last X-ray
- 444 First Visit or Consultation
Check with each payer to find out if they would like a date reported in this field.
Why was a qualifier added to Item Number 17?
It was added in to specifically identify the role of the provider being reported in the field. The choices include:
- DN Referring Provider
- DK Ordering Provider
- DQ Supervising Provider
Most payers do not require chiropractors to report these qualifiers; but if, for example, you ordered physical therapy to be performed by someone else, that individual might use DK, and list the DC’s NPI in item 17b.
Can I still report other data in item 19 as it changed from “Reserved for Local Use” to “Additional Claim Information”?
The NUCC renamed this field in order to limit the use of open text. Dozens of qualifiers can be used here to help the NUCC standardize its use. Each qualifier should be separated by three spaces. When reporting supplemental claim information, use the qualifier “PWK,” followed by the appropriate “Report Type” qualifier. Some useful ones might be:
- 03 Report Justifying Treatment Beyond Utilization
- 09 Progress Report
- B4 Referral Form
- CB Chiropractic Justification
- EB Explanation of Benefits (for Medicare secondary payer)
- PY Physician’s Report
- RB Radiology Films
- RR Radiology Reports
What changed in item 21?
This is perhaps the most significant change to the latest version of the 1500 Claim Form. There is an indicator field where a “9” signifies that the claim form only uses ICD-9 codes. After October 1, 2015, a “0” will be reported in that field to indicate that ICD-10 codes were used. The lines were relabeled as “A–L” rather than “1–4,” reoriented horizontally, and the decimal was removed. This followed feedback that the NUCC received from the industry and will allow for more accurate reporting of ICD-10 codes.
Why was “Medicaid” removed from Item Number 22?
This field is no longer specific to Medicaid and can be used for resubmissions for any payer. This field would not be filled out with original submissions. There are two qualifiers to choose from:
- 7 Replacement of prior claim
- 8 Void/cancel of prior claim
Check with individual payers for guidelines.
Can open fields be used to report any data, even though they are marked “Reserved for NUCC use”?
No. The NUCC will take input from the industry to decide how to use these fields in the future. This ensures that the 1500 Claim Form is still universal and standardized. If providers were to customize the form, it would lose its purpose.
Why doesn’t the 1500 Claim Form include fields to report coordination of benefits (COB) data?
The NUCC determined that the form cannot accommodate the volume of information needed to properly report COB, therefore, the decision was made to instruct providers to attach the explanation of benefits (EOB) from the primary payer.
Do I have to use the form printed in red ink or can I use a black copy?
For the form to be read properly by a scanner, it must be in red ink. Optical character recognition software drops the red ink from the scanned image, which makes it easier to process.
If my payer has instructions that differ from those of NUCC, what should I do?
Follow payer-specific guidelines when they are provided to you, preferably in writing.
The 1500 Claim Form is the first step in securing payment for services. As such, a yearly review of the updates to the instructions can help you avoid costly mistakes and ensure that you are filing clean claims. The official instructions can be found at nucc.org and cms.gov.
Evan M. Gwilliam, DC, MBA, CPC, NCICS, CCPC, CCCPC, CPC- I, MCS-P, CPM, is a vice president and director of education and consulting for the ChiroCode Institute and is the only chiropractor certified by the AAPC as an ICD-10 trainer. His company’s annual book, ChiroCode DeskBook, provides a summarized guide to the 1500 Claim Form and is endorsed by the American Chiropractic Association. He teaches chiropractors and other health professionals how to prepare for ICD-10 and can be contacted at firstname.lastname@example.org.