ComplyRight CMS-1500 Health Insurance Claim Form

Meet billing requirements for Medicare part B using these ComplyRight CMS-1500 health insurance claim forms.
Use these easy-to-read insurance claim forms for a faster claims process. Printed in scannable, dropout OCR red ink, these documents deliver crisp, clean text and comply with CMS standards and requirements for paper, layout and ink to expedite the receipt of payment for health care facilities. These ComplyRight CMS-1500 forms include 02/12 NUCC revisions and replace the previous 08/05 version.

• Approved by the National Uniform Claim Committee (NUCC); HIPAA compliant
• This form was revised to align the paper form with some of the changes in the electronic healthcare claims: Professional (837), 005010X222 Technical Report Type 3 (5010) and 005010X222A1 Technical Report Type 3 (5010A1)
• The most significant change was the addition of 8 diagnosis codes in field 21
• Includes new QR code identifier at the top of the form that supports and aligns with Industry scanning systems

SKU:	A-10018383
MFR #:	CMS12LC250