The National Uniform Claim Committee (NUCC) has approved an updated version of its 1500 Health Insurance ClaimForm (CMS-1500 claim form). The new claim form, which goes into effect January 6, 2014, will accommodate reportingneeds for ICD-10 as well as align with data captured on electronic 837P transactions. The primary change to the form isthat the number of diagnosis codes that can be reported has been increased from four to 12 (see sample below).

Revised (2/2014): AmeriHealth will accept both the old (08/05) and new (02/12) claim forms from January 6 through March 31, 2014. Effective April 1, 2014, providers must use the new (02/12) claim form.

The NUCC has released an updated 1500 Health Insurance Claim Form Reference Instruction Manual, which is available under the 1500 Claim Form tab on their website at www.nucc.org.

Forms can be purchased through office supply stores, local printing companies, or by calling the U.S. GovernmentPrinting Office at
1-866-512-1800.

If you have any questions, please contact your Network Coordinator.