Forms
NPI Assignment Form You may save this form to your personal drive and submit as an email attachment if you choose.
National Uniform Billing Committee (NUBC)
UB-92 Claim Form
UB-04 Form - Effective March 1, 2007
National Uniform Claim Committee (NUCC)
CMS 1500 Health Insurance Claim Form
Revised CMS 1500 Health Insurance Claim Form (8/05) – Effective April 1, 2007
Completion of the Revised HCFA 1500 Claim Form:
The instructions provided by CMS on how to complete the revised HCFA 1500 claim form due to the NPI requirement are included on this website under the link to the revised form itself.
Physicians Plus Insurance Corporation will follow these instructions. It is our interpretation based on the CMS instructions that the NPI information on the form be completed as follows:
Box 24j is to be used to report the Type 1 NPI for individual providers that are part of an organization or are incorporated. In this situation the Type 2 NPI is reported in box 33a. Box 33a is to be used to report the Type 1 NPI for individuals that are independent and are NOT incorporated.
In July 2006, the Form CMS-1500 (12-90) was revised by the National Uniform Claim Committee (NUCC) predominantly for the purpose of accommodating the National Provider Identifier. Since that time, the industry has been preparing for the implementation of the revised Form CMS-1500 (08-05). In September 2006, Medicare announced that it would implement the revised Form CMS-1500 (08-05) on January 1, 2007 with dual acceptability of both versions until March 31, 2007. Medicare further announced that beginning April 1, 2007, the only acceptable version of the form would be the Form CMS-1500 (08-05) and that the prior version, Form CMS-1500 (12-90), would be rejected.
It has recently come to our attention that there are incorrectly formatted versions of the revised form being sold by print vendors, specifically the Government Printing Office (GPO). After reviewing the situation, the GPO has determined that the source files they received from the NUCC’s authorized forms designer were improperly formatted. This resulted in the sale of both printed forms and negatives which do not comply with the form specifications.
Given the circumstances, CMS has decided to extend the acceptance period of the Form CMS-1500 (12-90) version beyond the original April 1, 2007 deadline while this situation is resolved. Medicare contractors will be directed to continue to accept the Form CMS-1500 (12-90) until notified by CMS to cease. At present, we are targeting June 1, 2007 as that date. In addition, during the interim, contractors will be directed to return, not manually key, any Form CMS-1500 (08-05) forms received which are not printed to specification. By returning the incorrectly formatted claim forms back to you, we are able to make you aware of the situation which will allow you to begin communications with your form supplier.
The following will help you to properly identify which form is which. The old version of the form contains “Approved OMB-0938-0008 FORM CMS-1500 (12-90)” on the bottom of the form (typically on the lower right corner) signifying the version is the December 1990 version. The revised version contains “Approved OMB-0938-0999 FORM CMS-1500 (08-05)” on the bottom of the form signifying the version is the August 2005 version. The best way to identify if your CMS-1500 (08-05) version forms are correct is by looking at the upper right hand corner of the form. On properly formatted claim forms, there will be approximately a ¼” gap between the tip of the red arrow above the vertically stacked word “CARRIER” and the top edge of the paper. If the tip of the red arrow is touching or close to touching the top edge of the paper, then the form is not printed to specifications.
Questions may be directed to Brian Reitz at Brian.Reitz@cms.hhs.gov .
News
1/07 OMB Approves UB-04 Form
1/07 NUCC – Revised 1500 Claim Form
9/06 NPI FAQs for the Dental Community
NPI Updates
10/06: Important NPI Claims Processing Information
All participating providers will be required to obtain and submit with an NPI as of the compliance date (May 2007). The legacy provider ID number will continue to be used until Physicians Plus is ready to receive and process claims with the NPI.
Physicians Plus will not require non-participating providers to submit claims with a NPI. However, if a NPI is available it is the preferred option. If the provider is not assigned a NPI the claim will process using a legacy provider ID number.
For additional information, please click here for frequently asked questions and implementation updates.
Correspondence from Physicians Plus Regarding NPI
New Claims Information for Dental Providers
The ADA Dental Claim Form provides a common format for reporting dental services to a patient’s dental benefit plan. ADA policy promotes use and acceptance of the most current version of the ADA Dental Claim Form by dentists and payers.
The latest version of the dental claim form enables reporting of a National Provider Identifier (NPI), in addition to a current proprietary provider identifier, for both the Billing Dentist/Dental Entity and for the Treating Dentist. This version of the form becomes valid for use on January 1, 2007.
Three samples of the ADA Dental Claim Form are available for your review. Click here to attain the forms.
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