Printing Standards and Print File Specifications Form CMS-1500

30 - Printing Standards and Print File Specifications Form CMS-1500 (Rev. 899, Issued: 03-31-06; Effective: 10-01-06; Implementation: 10-02-06) The National Uniform Claims Committee (NUCC) has approved the printing standards for Form CMS-1500 (08-05) paper claim. These standards are as follows: The Form CMS-1500 (08-05) is designed to accommodate 10-pitch Pica type, 6 lines per inch vertical and 10 characters per inch (cpi) horizontal. Once adjusted to the left and right, PICA Alignment blocks in the first print line and characters appear within form lines as shown in the print file matrix. Also provided on the Form CMS-1500 (08-05) is a position bar. This is a thick horizontal line that is at the base of the PICA alignment Boxes. The Form CMS-1500 (08-05) is used in four different styles. Any one of these four styles may be printed from two negatives in concurrence with the layout that was approved by the NUCC. The face/back negative furnished must be used for all parts. Compliance with these standards is required to facilitate the use of image processing technology such as Optical Character Recognition (OCR), facsimile transmission, and image storing. Cut Sheet: Size - 8.5 by 11 inches (plus or minus .0625 inch) or 217mm by 279mm (plus or minus 2mm). Print - Face and back, head to head. Margins - Face - The top margin from the top edge of the form to the first print position is 1.33 inches or 34mm. The left margin is 0.3 inches to the left end of the first print position. Back - 0.25 inch head and foot, 0.25 inch left and right or 6.35 mm head and foot, 6.35 mm left and right. Offset - The X and Y offset for margins must not vary by more than +/-0.1 inch or 2.54 mm from sheet to sheet. The X offset refers to the horizontal distance from the left edge of the paper to the beginning of the printing. The Y offset refers to the vertical distance between the top of the paper and the beginning of the printing. Askewity - The askewity of the printed image must be no greater than 0.15mm in 100mm. Paper Stock - Basis weight 20# recycled 30% postconsumer waste, White Environmental Paper Alliance (EPA) or approved paper stock. Smoothness: FS to be (140-160), or equivalent stock. Ink color - Face - (OCR-Red Ink) must be in Flint J-6983 Red OCR “dropout” ink or an exact match, formerly known as Sinclair Valentine). There is to be no contamination with “Black” ink or pigment. Printer must maintain proper ink reflections limits of the OCR reader specified by the purchaser. Back - Same as face. Titles - Color of any titles if applicable: Are to be in the same ink as the form, Flint J6983 OCR Red “dropout” ink. Symbol - The identifiable 1500 in a rectangle located in the upper left front of the form above the PICA boxes is to be in black ink. Two Part Snap-set: Size - Dimensions are same as Cut Sheet (detached 8.5 by 11 inches), plus top stub (.5 to .75 inches). Print - Part 1 - Face and back - head to head. Part 2 - Face and back - head to head. Margins - Same as Cut Sheet. Askewity - Same as Cut Sheet. Stock - Part 1 - Carbonless, 20 CB - Recycled White Part 2 - Any color that will not interfere with scanning of Part 1 sheet. Ink Color - Part 1 - (OCR-Red Ink) must be in Flint J-6983 Red OCR “dropout” ink or an exact match. Part 2 - Any color that will not interfere with scanning of Part 1 sheet. Titles - Color of any titles if applicable: Are to be in the same ink as the form, Flint J6983 OCR Red “dropout” ink. Symbol - The identifiable 1500 in a rectangle located in the upper left front of the form above the PICA boxes is to be in black ink. Perforations - Perforate top stub for disassembly of parts. One Part Marginally Punched Continuous Form: Size - Same dimensions as for Cut Sheet, plus 0.5 inch left and right, (overall: 9.5 by 11 inches, detached: 8.5 by 11 inches). Print - Face and back, head to head. Margins - On detached sheet, same as for Cut Sheet. Askewity - On detached sheet, same as for Cut Sheet. Paper Stock - Same as for Cut Sheet. Ink Color - Same as for Cut Sheet (OCR-Red Ink) must be in Flint J-6983 Red OCR “dropout” ink or an exact match. Titles - Color of any titles if applicable: Are to be in the same ink as the form, Flint J6983 OCR Red “dropout” ink. Symbol - The identifiable 1500 in a rectangle located in the upper left front of the form above the PICA boxes is to be in black ink. Perforations - Marginally 0.5 inch left and right, tear line horizontally every 11 inches. Two Part Marginally Punched Continuous Forms: Size - Same dimensions as for Cut Sheet, plus 0.5 inch left and right, (overall: 9.5 by 11 inches, detached: 8.5 by 11 inches). Print - Part 1 -Face and back, head to head. Part 2 -Face and back, head to head. Margins - On detached sheet, same as for Cut Sheet. Askewity - On detached sheet, same as for Cut Sheet. Paper Stock - Part 1 - Carbonless, 20 CB - Recycled White Part 2 - Any color or weight that does not interfere with scanning of part 1 sheet. Suggest the following sequence: Paper Weight: 1st part is 20 CB - OCR Bond 2nd part is 14 CFB (if not last part) Last part is 15CF CB = Coated Back (Carbonless black print) CFB = Coated Front and Back (Carbonless black print) CF = Coated Front (Carbonless black print) Ink color - Part 1 - Same as for cut sheet, (OCR-Red Ink) must be in Flint J-6983 Red OCR “dropout” ink or an exact match. Part 2 - Any color that will not interfere with scanning of the part 1 sheet. Titles - Color of any titles if applicable: Are to be in the same ink as the form, Flint J6983 OCR Red “dropout” ink. Symbol - The identifiable 1500 in a rectangle located in the upper left front of the form above the PICA boxes is to be in black ink. Joining - Crimp left and right. Perforations - Marginally 0.5 inch left and right, tear line horizontally every 11”. NOTE: Users may determine the number of parts that are applicable to their needs. Up to four total parts are feasible on some printers; some other printers may limit the readability of multiple plies. Color of any titles if applicable: Are to be in the same ink as the form, Flint J6983 OCR Red “dropout” ink. Symbol: NUCC requires the use of an approved Form CMS-1500 in the formats provided displaying the 1500 symbol as approved by the NUCC. All printing of Form CMS-1500 must occur in accordance with the NUCC requirements. Form Name - CMS-1500 Health Insurance Paper Claim Form, Approved by the National Uniform Claims Committee (NUCC). Form Identification: The lower right-hand margin contains the approved OMB numbers and should be consistent throughout. No modification is to be made to the Form CMS-1500 (08-05) without prior approval from the NUCC and CMS. Exhibit 1 (Rev. 1970, 05-21-10) Form CMS-1500 (08/05) User Print File Specifications (Formerly Exhibit 2) LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 1 Left printer alignment block M 3 01-03 1 Right printer alignment block M 3 77-79 3 1 Medicare M 1 01 3 1 Medicaid M 1 08 3 1 Tricare Champus M 1 15 3 1 Champva M 1 24 3 1 Group Health Plan M 1 31 3 1 FECA Blk Lung M 1 39 3 1 Other M 1 45 3 1a Insured's ID Number A/N 29 50-78 5 2 Patient's Name (Last, First, MI) A 28 01-28 5 3 Patient's Birth Date (Month) N 2 31-32 5 3 Patient's Birth Date (Day) N 2 34-35 5 3 Patient's Birth (Year) N 4 37-40 5 3 Sex-Male M 1 42 5 3 Sex-Female M 1 47 5 4 Insured Name (Last, First, MI) A 29 50-78 7 5 Patient's Address A/N 28 01-28 7 6 Patient Relationship to Insured (Self) M 1 33 7 6 Patient Relationship to Insured (Spouse) M 1 38 7 6 Patient Relationship to Insured (Child) M 1 42 7 6 Patient Relationship to Insured (Other) M 1 47 7 7 Insured's Address A/N 29 50-78 9 5 Patient's City A 24 01-24 * M = mark (X), A = alpha, N = numeric 9 5 Patient's State A 3 26-28 9 8 Patient Status (Single) M 1 35 LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 9 8 Patient Status (Married) M 1 41 9 8 Patient Status (Other) M 1 47 9 7 Insured's City A 23 50-72 9 7 Insured's State A 4 74-77 11 5 Patient's ZIP Code N 12 01-12 11 5 Patient's Area Code N 3 15-17 11 5 Patient's Phone Number N 10 19-28 11 8 Patient Status (Employed) M 1 35 11 8 Patient Status (Full Time Student) M 1 41 11 8 Patient Status (Part Time Student) M 1 47 11 7 Insured's ZIP Code N 12 50-61 11 7 Insured's Area Code N 3 65-67 11 7 Insured's Phone Number N 10 69-78 13 9 Other Insured's Name (Last, First, MI) A 28 01-28 13 11 Insured's Policy, Group or FECA Number A/N 29 50-78 15 9a Other Insured's Policy or Group Number A/N 28 01-28 15 10a Condition Related (Employment C/P, Yes) M 1 35 15 10a Condition Related (Employment C/P, No) M 1 41 15 11a Insured's Date of Birth (Month) N 2 53-54 15 11a Insured's Date of Birth (Day) N 2 56-57 15 11a Insured's Date of Birth (Year) N 4 59-62 15 11a Sex-Male M 1 68 15 11a Sex-Female M 1 75 17 9b Other Insured's Date of Birth (Month) N 2 02-03 * M = mark (X), A = alpha, N = numeric 17 9b Other Insured's Date of Birth (Day) N 2 05-06 17 9b Other Insured's Date of Birth (Year) N 4 08-11 LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 17 9b Sex-Male M 1 18 17 9b Sex-Female M 1 24 17 10b Condition Related To: (Auto Accident- Yes) M 1 35 17 10b Condition Related To: (Auto Accident- No) M 1 41 17 10b Condition Related To: (Auto Accident- State) A 2 45-46 17 11b Insured's Employer's Name or School Name A/N 29 50-78 19 9c Other Insured's Employer's Name or School A/N 28 01-28 19 10c Other Accident (Yes) M 1 35 19 10c Other Accident (No) M 1 41 19 11c Insured's Insurance Plan or PayerID A/N 29 50-78 21 9d Other Insured’s Plan Name or Payer ID A/N 28 01-28 21 10d (Reserved for Local Use) A/N 19 30-48 21 11d Another Benefit Health Plan (Yes) M 1 52 21 11d Another Benefit Health Plan (No) M 1 57 25 12 Left Blank for Patient's Signature & Date 25 13 Left Blank for Insured's Signature 27 14 Date of Current Illness, Injury, Pregnancy (Month) N 2 02-03 27 14 Date of Current Illness, Injury, Pregnancy (Day) N 2 05-06 27 14 Date of Current Illness, Injury, Pregnancy - (Year) N 4 08-11 27 15 First Date Has Had Same or Similar Illness (Month) N 2 37-38 * M = mark (X), A = alpha, N = numeric 27 15 First Date Has Had Same or Similar Illness (Day) N 2 40-41 27 15 First Date Has Had Same or Similar Illness - (Year) N 4 43-46 LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 27 16 Dates Patient Unable to Work (From Month) N 2 54-55 27 16 Dates Patient Unable to Work (From Day) N 2 57-58 27 16 Dates Patient Unable to Work (From Year) N 4 60-63 27 16 Dates Patient Unable to Work (To Month) N 2 68-69 27 16 Dates Patient Unable to Work (To Day) N 2 71-72 27 16 Dates Patient Unable to Work (To Year) N 4 74-787 28 17a Legacy Qualifier/Provider Number of Referring Physician A/N 19 30-48 29 17 Name of Referring Physician or Other Source A 26 01-26 29 17b NPI Number of Referring Physician N 17 32-48 29 18 Hospitalization Related Current Svcs (From Month) N 2 54-55 29 18 Hospitalization Related Current Svcs (From Day) N 2 57-58 29 18 Hospitalization Related Current Svcs (From Year) N 4 60-63 29 18 Hospitalization Related Current Svcs (To Month) N 2 68-69 29 18 Hospitalization Related Current Svcs (To Day) N 2 71-72 29 18 Hospitalization Related Current Svcs (To Year) N 30 19 Reserved for Local Use A/N 35 14-48 31 19 Reserved for Local Use A/N 48 01-48 31 20 Outside Lab (Yes) M 1 52 * M = mark (X), A = alpha, N = numeric 31 20 Outside Lab (No) M 1 57 31 20 $ Charges N 8/8 62-78 LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 33 21.1 Diagnosis or Nature of Illness or Injury (Code) A/N 8 03-10 33 21.3 Diagnosis or Nature of Illness or Injury (Code) A/N 8 30-37 33 22 Medicaid Resubmission Code A/N 11 50-60 33 22.2 Original Reference Number A/N 18 61-78 35 21.2 Diagnosis or Nature of Illness or Injury (Code) A/N 8 03-10 35 21.4 Diagnosis or Nature of Illness or Injury (Code) A/N 8 30-37 35 23 Prior Authorization Number A/N 29 50-78 38 24 Line Detail Narrative A/N 63 01-63 38 24.1i Legacy Qualifier Rendering Provider A/N 2 65-66 38 24.1j Legacy Provider Number Rendering Provider A/N 11 68-78 39 24.1a Date(s) of Service - (From Month) N 2 01-02 39 24.1a Date(s) of Service - (From Day) N 2 04-05 39 24.1a Date(s) of Service - (From Year) N 2 07-08 39 24.1a Date(s) of Service - (To Month) N 2 10-11 39 24.1a Date(s) of Service - (To Day) N 2 13-14 39 24.1a Date(s) of Service - (To Year) N 2 16-17 39 24.1b Place of Service A/N 2 19-20 39 24.1c EMG A 2 22-23 39 24.1d Procedures, Svcs or Supplies (CPT/HCPCS) A/N 6 25-30 39 24.1d Procedures, Svcs or Supplies (Modifier 1) A/N 2 33-34 39 24.1d Procedures, Svcs or Supplies (Modifier 2) A/N 2 36-37 39 24.1d Procedures, Svcs or Supplies (Modifier 3) A/N 2 39-40 39 24.1d Procedures, Svcs or Supplies (Modifier 4) A/N 2 42-43 * M = mark (X), A = alpha, N = numeric 39 24.1e Diagnosis Pointer N 4 45-48 39 24.1f $ Charges N 8 50-57 LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 39 24.1g Days or Units N 3 59-61 39 24.1h EPSDT Family Plan A 1 63 39 24.li Legacy Qualifier Rendering Provider (Leave Blank) A/N 0 39 24.1j Legacy Provider Number Rendering Provider A/N 11 68-78 40 24 Line Detail Narrative A/N 63 01-63 40 24.2i Legacy Qualifier Rendering Provider A/N 2 65-66 40 24.2j Legacy Provider Number Rendering Provider A/N 11 68-78 41 24.2a Date(s) of Service - (From Month) N 2 01-02 41 24.2a Date(s) of Service - (From Day) N 2 04-05 41 24.2a Date(s) of Service - (From Year) N 2 07-08 41 24.2a Date(s) of Service - (To Month) N 2 10-11 41 24.2a Date(s) of Service - (To Day) N 2 13-14 41 24.2a Date(s) of Service - (To Year) N 2 16-17 41 24.2b Place of Service A/N 2 19-20 41 24.2c EMG A 2 22-23 41 24.2d Procedures, Svcs or Supplies (CPT/HCPCS) A/N 6 25-30 41 24.2d Procedures, Svcs or Supplies (Modifier 1) A/N 2 33-34 41 24.2d Procedures, Svcs or Supplies (Modifier 2) A/N 2 36-37 41 24.2d Procedures, Svcs or Supplies (Modifier 3) A/N 2 39-40 41 24.2d Procedures, Svcs or Supplies (Modifier 4) A/N 2 42-43 41 24.2e Diagnosis Pointer N 4 45-48 41 24.2f $ Charges N 8 50-57 41 24.2g Days or Units N 3 59-61 41 24.2h EPSDT Family Plan A 1 63 * M = mark (X), A = alpha, N = numeric 41 24.2i Legacy Qualifier Rendering Provider (Leave Blank) A/N 0 LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 41 24.2j Legacy Provider Number Rendering Provider A/N 11 68-78 42 24 Line Detail Narrative A/N 63 01-63 42 24.3i Legacy Qualifier Rendering Provider A/N 2 65-66 42 24.3j Legacy Provider Number Rendering Provider A/N 11 68-78 43 24.3a Date(s) of Service - (From Month) N 2 01-02 43 24.3a Date(s) of Service - (From Day) N 2 04-05 43 24.3a Date(s) of Service - (From Year) N 2 07-08 43 24.3a Date(s) of Service - (To Month) N 2 10-11 43 24.3a Date(s) of Service - (To Day) N 2 13-14 43 24.3a Date(s) of Service - (To Year) N 2 16-17 43 24.3b Place of Service A/N 2 19-20 43 24.3c EMG A 2 22-23 43 24.3d Procedures, Svcs or Supplies (CPT/HCPCS) A/N 6 25-30 43 24.3d Procedures, Svcs or Supplies (Modifier 1) A/N 2 33-34 43 24.3d Procedures, Svcs or Supplies (Modifier 2) A/N 2 36-37 43 24.3d Procedures, Svcs or Supplies (Modifier 3) A/N 2 39-40 43 24.3d Procedures, Svcs or Supplies (Modifier 4) A/N 2 42-43 43 24.3e Diagnosis Pointer N 4 45-48 43 24.3f $ Charges N 8 50-57 43 24.3g Days or Units N 3 59-61 43 24.3h EPSDT Family Plan A 1 63 43 24.3i Legacy Qualifier Rendering Provider (Leave Blank) A/N 0 43 24.3j Legacy Provider Number Rendering Provider A/N 11 68-78 44 24 Line Detail Narrative A/N 63 01-63 * M = mark (X), A = alpha, N = numeric 44 24.4i Legacy Qualifier Rendering Provider A/N 2 65-66 LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 44 24.4j Legacy Provider Number Rendering Provider A/N 11 68-78 45 24.4a Date(s) of Service - (From Month) N 2 01-02 45 24.4a Date(s) of Service - (From Day) N 2 04-05 45 24.4a Date(s) of Service - (From Year) N 2 07-08 45 24.4a Date(s) of Service - (To Month) N 2 10-11 45 24.4a Date(s) of Service - (To Day) N 2 13-14 45 24.4a Date(s) of Service - (To Year) N 2 16-17 45 24.4b Place of Service A/N 2 19-20 45 24.4c EMG A 2 22-23 45 24.4d Procedures, Svcs or Supplies (CPT/HCPCS) A/N 6 25-30 45 24.4d Procedures, Svcs or Supplies (Modifier 1) A/N 2 33-34 45 24.4d Procedures, Svcs or Supplies (Modifier 2) A/N 2 36-37 45 24.4d Procedures, Svcs or Supplies (Modifier 3) A/N 2 39-40 45 24.4d Procedures, Svcs or Supplies (Modifier 4) A/N 2 42-43 45 24.4e Diagnosis Pointer N 4 45-48 45 24.4f $ Charges N 8 50-57 45 24.4g Days or Units N 3 59-61 45 24.4h EPSDT Family Plan A 1 63 45 24.4i Legacy Qualifier Rendering Provider Blank) (Leave A/N 0 45 24.4j Legacy Provider Number Rendering Provider A/N 11 68-78 46 24 Line Detail Narrative A/N 63 01-63 46 24.5i Legacy Qualifier Rendering Provider A/N 2 65-66 46 24.5j Legacy Provider Number Rendering Provider A/N 11 68-78 47 24.5a Date(s) of Service - (From Month) N 2 01-02 * M = mark (X), A = alpha, N = numeric 47 24.5a Date(s) of Service - (From Day) N 2 04-05 LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 47 24.5a Date(s) of Service - (From Year) N 2 07-08 47 24.5a Date(s) of Service - (To Month) N 2 10-11 47 24.5a Date(s) of Service - (To Day) N 2 13-14 47 24.5a Date(s) of Service - (To Year) N 2 16-17 47 24.5b Place of Service A/N 2 19-20 47 24.5c EMG A 2 22-23 47 24.5d Procedures, Svcs or Supplies (CPT/HCPCS) A/N 6 25-30 47 24.5d Procedures, Svcs or Supplies (Modifier 1) A/N 2 33-34 47 24.5d Procedures, Svcs or Supplies (Modifier 2) A/N 2 36-37 47 24.5d Procedures, Svcs or Supplies (Modifier 3) A/N 2 39-40 47 24.5d Procedures, Svcs or Supplies (Modifier 4) A/N 2 42-43 47 24.5e Diagnosis Pointer N 4 45-48 47 24.5f $ Charges N 8 50-57 47 24.5g Days or Units N 3 59-61 47 24.5h EPSDT Family Plan A 1 63 47 24.5i Legacy Qualifier Rendering Provider (Leave Blank) A/N 0 47 24.5j Legacy Provider Number Rendering Provider A/N 11 68-78 48 24 Line Detail Narrative A/N 63 01-63 48 24.6i Legacy Qualifier Rendering Provider A/N 2 65-66 48 24.6j Legacy Provider Number Rendering Provider A/N 11 68-78 49 24.6a Date(s) of Service - (From Month) N 2 01-02 49 24.6a Date(s) of Service - (From Day) N 2 04-05 49 24.6a Date(s) of Service - (From Year) N 2 07-08 49 24.6a Date(s) of Service - (To Month) N 2 10-11 49 24.6a Date(s) of Service - (To Day) N 2 13-14 * M = mark (X), A = alpha, N = numeric 49 24.6a Date(s) of Service - (To Year) N 2 16-17 LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 49 24.6b Place of Service A/N 2 19-20 49 24.6c EMG A 2 22-23 49 24.6d Procedures, Svcs or Supplies (CPT/HCPCS) A/N 6 25-30 49 24.6d Procedures, Svcs or Supplies (Modifier 1) A/N 2 33-34 49 24.6d Procedures, Svcs or Supplies (Modifier 2) A/N 2 36-37 49 24.6d Procedures, Svcs or Supplies (Modifier 3) A/N 2 39-40 49 24.6d Procedures, Svcs or Supplies (Modifier 4) A/N 2 42-43 49 24.6e Diagnosis Pointer N 4 45-48 49 24.6f $ Charges N 8 50-57 49 24.6g Days or Units N 3 59-61 49 24.6h EPSDT Family Plan A 1 63 49 24.6i Legacy Qualifier Rendering Provider (Leave Blank) A/N 0 49 24.6j Legacy Provider Number Rendering Provider A/N 11 68-78 51 25 Federal Tax ID Number N 15 1-15 51 25 Federal Tax ID Number (SSN) M 1 17 51 25 Federal Tax ID Number (EIN) M 1 19 51 26 Patient's Account Number A/N 14 23-36 51 27 Accept Assignment (Yes) M 1 38 51 27 Accept Assignment (No) M 1 43 51 28 Total Charge N 9 51-59 51 29 Amount Paid N 8 62-69 51 30 Balance Due N 8 71-78 52 33 Billing Provider Phone Number Area Code N 3 66-68 52 33 Billing Provider Phone Number N 9 70-78 * M = mark (X), A = alpha, N = numeric 53 32 Name of Facility Where Svcs Rendered A/N 26 23-48 LINE FIELD LITERAL FIELD TYPE* BYTES COL- UMNS 53 33 Physician/Supplier Billing Name A/N 29 50-78 54 32 Address of Facility Where Svcs R d d A/N 26 23-48 54 33 Physician/Supplier Address A/N 29 50-78 55 31 Left Blank for Signature Physician/Supplier 55 32 City, State and ZIP Code of Facility A/N 26 23-48 55 33 City, State and ZIP Code of Billing P id A/N 29 50-78 56 32a Facility NPI Number N 10 24-33 56 32b Facility Qualifier and Legacy Number A/N 14 35-48 56 33a Billing Provider NPI Number N 10 51-60 56 33b Billing Provider Qualifier and Legacy N b A/N 17 62-78 * M = mark (X), A = alpha, N = numeric