Health Insurance Claim Form Nucc 02 12

Transition timeline the nucc has approved a transition timeline for the version 02 12 1500 health insurance claim form 1500 claim form.

Health insurance claim form nucc 02 12. Insured s name last name first name middle initial 7. The nucc has developed a 1500 reference instruction manual detailing how to complete the claim form. Number for program in item 1 4. Medicare medicaid tricare champva group health plan feca blk lung other 1a.

The current version of the instructions for the 02 12 1500 claim form was released in july 2020. This image should also not be used by forms printers to create the form 02 12 claim form. The purpose of this manual is to help standardize nationally the manner in which the form is being completed. The nucc does not process claims.

Health insurance claim form approved by national uniform claim committee nucc 02 12 for program in item 1 medicare medicaid id dod member id id id id 1. Cms 1500 02 12 health insurance claim form physician and non physician professional services laboratory independent diagnostic testing facilities idtf ambulance and other transportation epsdt service ambulatory surgical center family planning behavioral health service vision therapists speech physical and. Approved omb 0938 1197 form 1500 02 12 1a. Patient s birth date sex 4.

Insured s id number 2. It is the basic paper claim form prescribed by many payers for claims submitted by physicians and suppliers and in some cases for am bulance services. The 1500 health insurance claim form 1500 claim form answers th e needs of many health care payers. Send completed forms to the appropriate payer.