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CMS-1500 Health Insurance Claim Forms

for use by all medical facilities


Per the National Uniform Claim Committee (NUCC), all re-billing of claims is to be with the Version 02/12 form, even though earlier submissions may have been on the Version 08/05 form.

  • Significant changes from Version 08/05 in Version 02/12:
    Click to see details.


Version 02/12
CMS12LC CMS12LC CMS12LC
ITEM
NUMBER:
FORMS/PACK DESCRIPTION
Version 02/12 Laser CMS-1500 Forms:
CMS12LC 2500 LASER CUT SHEET
CMS12LC1 1000 LASER CUT SHEET
CMS12LC500 500 LASER CUT SHEET
CMS12LC250 250 LASER CUT SHEET
Version 02/12 Continuous CMS-1500 Forms:
CMS121 1000 1-PART CONTINUOUS pk 2500
CMS1211 1000 1-PART CONTINUOUS pk 1000
CMS122 1000 2-PART CONTINUOUS: WHITE/CANARY
CMS12W2 1000 2-PART CONTINUOUS: WHITE/WHITE
CMS123 1000 3-PART CONTINUOUS: WHITE/CANARY/PINK
Version 02/12 Continuous CMS-1500 Forms with Labels
CMS121B 1000 1-PART CONTINUOUS
CMS122B 1000 2-PART CONTINUOUS: WHITE/CANARY
Version 02/12 Snap-Apart CMS-1500 Forms:
CMS12S 1000 2-PART CONTINUOUS: WHITE/CANARY
The Center for Medicare and Medicaid Services (CMS) publishes the Medicare Claims Processing Manual which contains detailed instructions for filling out the CMS-1500 form. The manual is posted on-line as a downloadable PDF file.


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