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These health insurance claim forms are designed and approved by HCFA, a unit of the Federal Government All claims filed by health care providers must be submitted on these claim forms 1-part single sheets
ComplyRight™ CMS-1500 Health Insurance Claim Form (02/12); Laser-Cut Sheet, 2,500/Box
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 health care 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
Item # 901-CMS12LC
ComplyRight™ CMS-1500 Health Insurance Claim Form (02/12); Laser-Cut Sheet, 1000/Carton
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 health care 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
Item # 901-CMS12LC1
ComplyRight™ CMS-1500 Health Insurance Claim Form (02/12); Laser-Cut Sheet, 250/Box
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
Item # 901-CMS12LC250
Use Code: PP4GFT37
One-time use per customer.
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