(Medicare Claims Processing Manual)

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)