Medicare Part B 101 Manual

CMS-1500 Claim Form

General Information
Claim Filing Instructions for Paper and Electronic Submission
Regulations on Charging for Claim Form Completion
OCR System
Missing, Incomplete, Insufficient, or Invalid Claim Information
CMS-1500 Claim Form Completion Instructions

General Information

When a provider qualifies for a waiver from the ASCA requirements, the CMS-1500 claim form (Health Insurance Claim Form) is the standard claim form used by noninstitutional providers or suppliers that submit claims to National Government Services, Inc.

For detailed information, refer to the ASCA Requirements for Paper Claim Submissions.

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Claim Filing Instructions for Paper and Electronic Submission

Providers are required to submit claims to NGS Medicare Part B for their Medicare patients whether or not assignment is taken; MLN Matters^® SE0908: Mandatory Claims Submission and its Enforcement.

The provision requiring mandatory filing of the claim by providers also states that the provider(s):

Is prohibited from charging for completing and filing the claim;
Must complete the claim form and must submit the claim to NGS
Who fails to submit a claim is subject to sanctions

Assigned claims not filed within one year of the service date are not the beneficiary’s responsibility. Provider(s) may not complete the claim and then ask the Medicare patient to submit the claim.

In order to stay in compliance with Medicare law, a physician who treats a Medicare beneficiary for a Medicare-covered service must either:

Enroll in Medicare and submit a claim on that beneficiary's behalf for those services, or
Opt out of Medicare and enter into a private contract with the beneficiary for those services, or
Furnish the Medicare-covered services for free.

A physician who wants to treat (and receive payment from) a Medicare beneficiary will stay in compliance with the law by either enrolling in Medicare and filing claims on the beneficiary's behalf or by opting out of Medicare and entering into a private contract with the beneficiary.

Moreover, it is important to note that in order to receive a Medicare payment for covered items or services – whether directly from Medicare or from the beneficiary who is, in turn, reimbursed by Medicare, a provider or supplier must be enrolled in the Medicare Program. See the Code of Federal Regulations (CFR) Title 42, Part 424, Section 500 et seq. for the regulations regarding establishing and maintaining Medicare billing privileges.

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Regulations on Charging for Claim Form Completion

The CMS has established Medicare policy concerning the practice by providers of charging Medicare patients for completion of Medicare forms.

When providing covered services to Medicare beneficiaries, providers are required to submit claims for services and cannot charge beneficiaries for completing or filing Medicare claims. NGS will monitor compliance with these requirements and offenders may be subject to a Civil Monetary Penalties.

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OCR System

To reduce delays in processing claims, we ask that paper claim forms are prepared so our OCR system can process them appropriately.

All paper claims are required to be submitted using an original red/white CMS-1500 (02/12) form.
- Submission of the CMS 1500 (02/12) claim form should either be typed or computer printed forms. Handwritten forms can cause delays and errors in processing and slow down time for reimbursement.
The form is designed for typewritten characters 10 or 12 pitch (pica).
Use Courier New font for computer-generated claims.
Character fonts may not be mixed on the same form.
Ensure none of the characters touch.
Italics, bold or script may not be used.
Do not use special characters (dollar signs, decimals, dashes, asterisk, backslashes, punctuation).
Use upper case (CAPITAL) letters for all alpha characters.
Enter all information on the same horizontal plane.
Enter all information within the designated fields.
Extraneous data may not be printed, handwritten, or stamped on the form.
Corrections may not be handwritten in any data field. Pin feed edges are to be removed evenly at side perforations.
Black and white copies will be returned as unprocessable.
Use an ink jet or laser printer to complete the CMS-1500 claim form. Because claims submitted with dot matrix printers have breaks in the letters and numbers, OCR equipment is unable to properly read these claims. Suppliers using dot matrix printers risk slow or incorrect processing of their claims.
Ensure no lines from the printer cartridge are anywhere on the claim.
Old or worn print bands or ribbons should be avoided.

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Missing, Incomplete, Insufficient, or Invalid Claim Information

There are no reopening or appeal rights on rejected claims (telephone or written); therefore, please do not send any form of correspondence into our office for unprocessable (MA130) claim(s) rejections.

Detailed information with regard to unprocessable claims can be reviewed for definitions and instructions concerning the handling of incomplete or invalid claims at CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.1 through 80.3.2.1.3, and CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10; includes a listing of the claim field requirements.

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