Thursday, July 15, 2010

1500 claim form instructions- Current and revised claim form

Current and Revised 1500 Claim Forms and Instructions

The 1500 Claim Form and NPI

Revisions to the 1500 Claim Form include several fields that accommodate the use of your National Provider Identifier (NPI).Though the revised form accommodates NPI, you must continue to report current provider identification numbers in the appropriate shaded areas of the form (17a, 24J, 32b, and 33b) until otherwise notified. Current provider identification numbers must be preceded  by a two-character qualifier ID. This qualifier ID is the same as the qualifier ID used when billing electronically. If you do not currently bill electronically, please use the following ID: 1B

If you have obtained your NPI(s) and submitted them to us, you may begin to report them in addition to your current provider identification numbers on the revised 1500 Claim Form. If you have any questions regarding the NPI, the application process, or reporting your NPI to us, please contact your Network Coordinator or Provider Services.

Impact to You and Your Practice

In preparation for the acceptance of the revised form, you should arrange for your billing vendors to make any necessary updates to your billing practices. Look to upcoming articles in Partners In Health Update for additional details on the CMS implementation date of the revised 1500 Claim Form.

Important Revisions to the 1500 Claim Form

The revised 1500 Claim Form expands the length of some existing fields, incorporates several new fields, and accommodates use of your NPI. Some important fields that have been revised or added are listed below [new fields are bolded]:

Please Note: In addition to the revised fields, we will now require you to populate Field 19 with the ZZ qualifier ID and the Billing Provider’s Primary Taxonomy Code (Example: ZZ207LP2900X).


Field 17a part 1 and 2 Referring provider’s two-character qualifier ID (part 1), followed by the current provider identification number (part 2).

Field 17b, part 1 Pre-filled with “NPI.”


Field 17b, part 2 Referring provider’s NPI.

Field 21, parts 1-4 Diagnosis code fields have been updated to allow four characters of information following the pre-filled decimal point.

Field 24 The shaded area extending from fields 24A through 24G will accommodate supplemental information, such as the narrative description of unspecified codes.

Field 24C “EMG” (previously “Type of Service”). EMG was previously Field 24I.

Field 24D “Procedures, Services, or Supplies” has been extended by three characters; you may now record up to four modifiers on the same line.

Field 24E Now titled “Diagnosis Pointer” (previously “Diagnosis Code”); size decreased by three characters.

Field 24H “EPSDT Family Plan” decreased in size by one character.

Field 24I “ID. Qual” (previously “EMG”). The shaded area of this field (part 1) allows you to identify the two-character qualifier ID of the Rendering Provider (Example: 1B). The unshaded area (part 2) is pre-filled with “NPI.”

Field 24J “Rendering Provider ID #” (previously “COB”). The shaded area of this field (part 1) allows you to submit the current provider identification number of the Rendering Provider that coincides with the two-character qualifier ID reported in the shaded area of 24I (part 1). The unshaded area (part 2) accommodates the Rendering Provider NPI.

Field 32a Service Facility NPI.

Field 32b Service Facility two-character qualifier ID and current provider identification number (Example: 1B1234567002).


Field 33a Billing Provider NPI (previously “PIN#”).


Field 33b Billing Provider two-character qualifier ID and current provider identification number (Example: 1B1234567001) (previously “GRP#)



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