02/12 CMS 1500 Claim Form and Medisoft v19

Medisoft v19 is the only version that includes fields, programming, and report forms necessary to produce the new 02/12 CMS 1500 Claim form. 

Timeline

The NUCC (National Uniform Claim Committee) has approved a transition timeline for the version 02/12 CMS-1500 Claim Form. In June, the NUCC announced the approval of the updated 1500 Claim Form that accommodates reporting needs for ICD-10 and aligns with requirements in the Accredited Standards Committee X12 (ASC X12) Health Care Claim: Professional (837P) Version 5010 Technical Report Type 3.

The NUCC approved the following transition timeline at its in-person meeting in Chicago on August 1, 2013.

  • January 6, 2014: Payers begin receiving and processing paper claims submitted on the revised 02/12 CMS-1500 Claim Form.
  • January 6 through March 31, 2014: Dual use period during which payers continue to receive and process paper claims submitted on the old 1500 Claim Form (version 08/05).
  • April 1, 2014: Payers receive and process paper claims submitted only on the revised 02/12 CMS-1500 Claim Form.

New Claim forms built into Medisoft v19:

There are six new claim forms available in Medisoft v19:

  1. CMS-1500 (Primary) – 02/12 W/Form
  2. CMS-1500 (Primary) – 02/12
  3. CMS-1500 (Secondary) -02/12 W/Form
  4. CMS-1500 (Secondary) – 02/12
  5. CMS-1500 (Tertiary) – 02/12 W/Form
  6. CMS-1500 (Tertiary) – 02/12

These forms have been programmed to meet the recommendations for completing the new CMS- 1500 02/12 Claim Form. Forms with the words “W/Form” in the title indicate that the report will print both the claim data and the claim form itself on a white sheet of paper. Note that the form will print in black ink so if you have a payer that requires the form in red you will not be able to use this form. It is our understanding that most payers do accept it in black ink (Medicare being the exception).

The forms that do not have the words “W/Form” in the title are designed to print on a pre-printed claim form. Note that you may have to align the form to your specific printer.

There is no longer a separate form for Medicare claims as all of the forms have been programmed to look at the “Insurance Type” designated on the Insurance setup screen. When the type is set to “Medicare” the form will automatically complete the claim form with according to Medicare specifications for you.

Essentially the only choice you need to make is whether you are printing claims for the primary, secondary, or tertiary insurance and whether you want the claim form itself to print with the data, or if you want the data only so you can print it on a pre-printed claim form.

New Claim Forms

Changes to the CMS- 1500 Claim Form and where the data will pull from in Medisoft v19 SP1:

This article will only detail the boxes that changed on the new 02/12 form available in Medisoft v19 SP1. Where there are visual changes to the form, the images used in this article will display the 08/05 form is in black and the new 02/12 form will be depicted is in red. If there are no visual changes to the form only a description of the change will be included.

While Medisoft v19 included the new 02/12 forms, Medicare did not release their instructions on how to complete the 02/12 form for Medicare claims until after Medisoft v19 was released. Therefore, only Medisoft v19 SP1 has the 02/12 forms programmed to Medicare specifications. All other insurances can be billed using the forms available in both Medisoft v19 and Medisoft v19 SP1.

The information in this article assumes that the user is on Medisoft v19 SP1. For reference please see the release notes for: Medisoft 19 Release Notes & Medisoft 19 SP1 Release Notes

For instructions on where to obtain Medisoft v19 SP1 see: Medisoft v19 SP1

Form Changes:

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Box 1

Box 1 Insurance Type: Champus has been removed and changed to Tricare, SSN has been removed and replaced with ID.

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Box 2 Patient’s Name: The NUCC suggests not printing the patient’s name when the patient is the subscriber. However, the patient’s name will continue to print on the form.

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Box 4 Insured Name: This box now includes functionality for worker’s compensation. If the Insurance Type of the destination payer is worker’s compensation, the patient case employer name will print.

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Box 5 Patient’s Address: The phone number no longer prints based on the NUCC’s suggestion.

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Box 7 Employer Address: This box now includes functionality for worker’s compensation. If the Insurance Type of the destination payer is worker’s compensation, the patient case employer address will print.

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Note: New Fields have been added to Medisoft v19 to accommodate for changes on the 02/12 form where it indicates “Reserved for NUCC Use”. These fields are located on the Miscellaneous Tab in the Case.

New fields in case___________________________________________________________________

Box 8

Box 8 Reserved for NUCC use: (Was Patient Status) This box shows the value of the new “Box 8” field on the Miscellaneous tab of the Case window. (New field available only in Medisoft v19)

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Box 9 Other Insured’s Name: For Medicare primary claims: If the primary insurance type is Medicare and the EDI Extra 1/Medigap field for the secondary insurance is Y, then Medisoft will print the subscriber’s name according to the current rule. Otherwise, Medisoft will leave the box blank. This excludes the insurance type of Medicaid when Medicaid is the secondary insurance.

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Box 9a Other Insured’s Policy: For Medicare primary claims: If the primary insurance type is Medicare EDI Extra 1/Medigap field for the secondary insurance is Y, then Medisoft will print the policy number according to the current rule, with the word MGAP preceded before the printed value. This excludes the insurance type of Medicaid when Medicaid is the secondary insurance.

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Box 9b

Box 9b Reserved for NUCC use: (Was Date of Birth and Sex) This box shows the value of the new “Box 9b” field on the Miscellaneous tab of the Case window. (New field available only in Medisoft v19)

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10c

Box 9c Reserved for NUCC use: (Was Employer or School Name) This box shows the value of the new “Box 9c” field on the Miscellaneous tab of the Case window. (New field available only in Medisoft v19)

For Medicare primary claims:

  • If the primary insurance type is Medicare and the EDI Extra 1/Medigap field for the secondary insurance is Y AND the Plan Name is blank, Medisoft will print the secondary insurance address in the following format on one line.: 1257 Anywhere St. City MD 21204.
  • If the EDI/Extra 1 Medigap field is blank or it has a Y and the plan name has a value, Medisoft will leave this box blank.
  • This excludes the insurance type of Medicaid when Medicaid is the secondary insurance. Otherwise, Medisoft will use the current rules.

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Box 9d Insurance Name: For Medicare primary claims: If the primary insurance type is Medicare and the EDI Extra 1/Medigap field for the secondary insurance is Y, AND the Plan Name field has a value, then Medisoft will print the Plan name value. Otherwise, Medisoft will leave the box blank. This excludes the insurance type of Medicaid when Medicaid is the secondary insurance.

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10d

Box 10d Claim Codes (Designated by NUCC): (Was reserved for local use) This box will print multiple condition codes separated by a space. This information reflects information from the “Condition Codes” fields located on the Condition tab in the case.

Condition Codes

If the primary insurance type is Medicare and the secondary insurance type is Medicaid, Medisoft will print MCD preceded by the Medicaid policy number.

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Box 11 Insured’s Policy Group or FECA Number:

If the primary insurance is Medicare, NONE will print in this box.

For Medicare secondary claims: When the secondary Insurance type is Medicare, Medisoft will print the Primary Insurance Group Number.

Otherwise, Medisoft will print the insured’s policy group or FECA number This information comes from the Case window, Policy 1, 2, or 3 tab, Group Number field.

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Box 11a Insured’s DOB and Gender:

For Medicare primary claims: If the primary insurance is Medicare, Medisoft will then leave this box blank.

For Medicare secondary claims: If the secondary insurance is Medicare and the subscriber is not the patient, Medisoft will print the subscriber’s birth date.

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11b

Box 11b Other Claim ID (designated by NUCC): (Was Employer Name) This box will print the value in the claim number field, preceded by a Y4 qualifier. The Claim Number field is found on the Policy tab in the case.

Claim Number

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Box 11c Ins Plan or Program Name: For Medicare secondary claims: When the secondary Insurance type is Medicare, Medisoft will print the Primary Insurance Name. Otherwise, Medisoft will print the insured’s insurance plan name or program name. This information comes from the Insurance Carrier window, Address tab, Plan Name field. If there is no name in the Plan Name field, the insurance carrier name prints in this box.

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Box 11d Is there another health benefit plan? If the primary insurance is Medicare, this box will remain blank. Otherwise, if there is a value in the Insurance field of the Policy 1 or 2 tab in Cases, the Yes check box is selected. If that value is empty, the No check box is selected.

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14

Box 14 Date Current Illness Injury or LMP: In addition to the date, there is a new Qualifier Code. The date will pull from the “Injury/Illness/LMP Date” field on the Condition tab in the case.  The qualifier will populate based on the option selected for the “Illness Indicator” field on that same tab.

14 Qualifier

Illness Indicator

For Medicare primary and secondary claims: If Insurance type is Medicare, Medisoft will not print a qualifier in the qualifier section of the box. Current rules apply for the date.

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15

Box 15 Other Date: In addition to the date (selected based on which date field is completed on the Condition tab in the case in the order below), there is a new Qualifier Code:

15 Qual

If more than one of these is completed on the condition tab in the case, Medisoft will print the first one in the order listed above.

Condition Tab

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17

Box 17 Referring Provider: This box can be used for various physician types. There are new qualifiers indicating the physician’s type:

17 Qualifiers

  • Only one can be used. If more than one exists on the billing, the system will use the following order: 1. referring, 2. ordering, 3. supervising.
  • If both supervising and referring exist on the claim (pulled from the Account tab in the case), Medisoft will print the referring provider.

Referring Provider

  • If the Send Ordering Provider in Loop 2420E check box on the destination payer’s Insurance record (EDI- Eligibility tab) is selected and there is a referring physician, Medisoft will print DK (Ordering Provider) instead of DN.

Ordering Provider

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Box 17a Other ID: This box shows the ID of the provider from Box 17.

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Box 17b NPI Number: This box shows the NPI number of the provider from Box 17.

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19

Box 19 Additional Claim Information (designated by NUCC): (Was reserved for local use) Additional Claim Information (designated by NUCC)

  • If there is a Taxonomy Code in the Provider ID grid for the provider in Box 24j, Medisoft will use that information first for Box 19. The qualifier ZZ followed by the taxonomy value will print. For example, ZZ163WG0100X.
  • If there is a value in the Legacy Identifier 2 field for that provider, the Legacy Identifier 2 qualifier and value will print. For example, 0B98765466.
  • If the Payer type is Worker’s Comp, three blank spaces and the Transaction Entry EDI notes for PWK, in addition to the IDs listed above, will print.
  • If none of these conditions are met, Medisoft will print the value in the Local Use B field on the Case – Miscellaneous tab.

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21

Box 21 Diagnosis Codes: Diagnosis codes 5-12 (indicated as E-L) have been added. Diagnosis codes are listed in order from left to right on three lines with four codes per line. In addition, there is an ICD Code Set Indicator:

21 Ind

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Box 23 Prior Authorization Number: If there is no Prior Authorization Number, the Claim
Facility CLIA Number will print.

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Box 24e Diagnosis Codes: This value now accepts alpha characters. Previously, only numeric values were reflected.

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Box 24h EPSDT: Unshaded area: A Y will print if the EPSDT check box on the Case window – Medicaid-Tricare tab is selected, unless Code 1 of the EPSDT Referral Codes is populated. In that case, the code will be printed instead of Y.

Shaded area: If the EPSDT check box is selected and the Family Planning check box is selected, Y will be printed. If EPSDT is selected and Family planning is not, N will be printed.

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Box 24 Transaction Description: Shaded area: If an NDC code is used, N4 will be printed and then the transaction NDC Code, a single space, followed by the NDC Unit of Measurement and NDC Unit Count. If you have entered text in the description field for a transaction, ZZ followed by the transaction description will print. If both are used, the NDC information prints first.

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Box 29 Amount Paid: This field is left blank. On secondary claims, it will show the calculated amount paid by the primary insurance carrier.

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30

Box 30 Balance Due: No longer used.

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We highly recommend studying both the 02/12 1500 Instruction Manual found at Nucc.org and the Medisoft Release Notes found here: Medisoft 19 Release Notes

Note: Medicare did not release the instruction manual for the new CMS-1500 02/12 Form until after Medisoft v19 was released. Therefore, users will need to install Medisoft v19 in order to print a paper claim formatted to Medicare’s specifications. Links to download SP1 can be found here. The Medisoft 19 SP1 Release Notes contain instructions on how Medisoft v19 SP1 populates the claim form for Medicare.

DISCLAIMER: Although AZCOMP Technologies, Inc. makes every effort to ensure that information regarding billing guidelines are checked and accurate in both our documentation and training, it should be understood that our expertise is in the software itself and not in billing practices. Therefore, it is the sole responsibility of the user to study, interpret and remain abreast of billing requirements and deadlines, contacting authoritative sources directly as needed. Any claims documentation and training provided by AZCOMP Technologies, Inc. is based on our interpretation of the rules published by nucc.org and cms.gov and  are subject to change. Information and training provided is “as is” and without any express or implied warranties. AZCOMP Technologies, Inc. assumes no responsibility for any inaccuracies, errors, or omissions, expressly disclaiming liability for damages of any kind arising out of the use of, reference to or reliance on any content provided.