Red Cms 1500 Claim Form. Indicate the type(s) of insurance coverage. Web 30 situational for a claim with no coverage other than medicaid, enter the total from field 28.
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Type the data within the boundaries of the fields provided. If you write on the form, use black or blue ink and print clearly and legibly. Web to download and print your claim form: Web the only acceptable claim forms are those printed in flint ocr red, j6983, (or exact match) ink. Revised for form version 02/12 this change request (cr) 8509 revises the current cms 1500 claim form instructions to reflect the revised cms 1500 claim form, version 02/12. Form version 02/12 will replace the current cms 1500 claim form, 08/05, effective with claims received on and after april 1,. You can also use your computer to complete this form and then print it out to mail it. It is available in various formats (e.g., single copy, duplicate, etc.). Web cms 1500 dynamic list information. Ocr scanners drop out any red that is on the paper.
Avoid using old or worn ink cartridges, toner cartridges, or printer ribbons. Avoid using old or worn ink cartridges, toner cartridges, or printer ribbons. These red ink versions can be purchased from a printer company, such as the u.s. Most claims for these services and supplies may also be submitted through computer media claims (cmc). Medicare medicaid tricare champva other read back of form before completing & signing this form. Select download complete form if you want to generate the full, red cms 1500 form as a pdf. Do not use any other color ink such as blue, purple, or red. This form is maintained by the national uniform claim committee (nucc), an industry organization in which cms participates. Government printing office at the following address: Indicate the type(s) of insurance coverage. Select download field entries only if you want to only generate the data fields so you can print it onto a blank cms 1500 form.
