Claim Formats

10.1 - Claim Formats (Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014) A. - Institutional Claim Formats The ASC X12 837 institutional claim format, or where permissible, Form CMS-1450, Inpatient and/or Outpatient Billing, is used for all provider billing, except for the professional component of physicians services. (Refer to paragraph B for the appropriate professional claim formats.) The ASC X12 837 institutional claim format and Form CMS-1450 are processed by the provider's A/B MAC (A). See Chapter 25 for instructions for hospital services.) Providers submitting claims on paper are responsible for purchasing their own paper forms. B. - Professional Claim Formats The ASC X12 837 professional claim format, or where permissible, Form CMS-1500 is the prescribed format for claims prepared by physicians and nonphysician practitioners whether or not the claims are assigned. Institutional providers may use the ASC X12 837 professional claim format or the Form CMS-1500 to bill the A/B MAC (B) for the professional component of physicians' services where applicable. (For more information about the CMS-1500 claim form, refer to Chapter 26. Information about billing for physician and other supplier services can be found in this chapter as well as chapters throughout this manual relative to specific policies and topics.) Providers submitting claims on paper are responsible for purchasing their own paper forms. C. - Form CMS-1490S Patient's Request for Medicare Payment Only beneficiaries (or their representatives) who complete and file their own claims use this form. Providers have no need for this form.