1500 Paper Claim Form Reminder

The current 1500 Paper Claim Form (version 02/12) is designed by The National Uniform Claim Committee (NUCC) to accommodate ICD-10 reporting needs. Generally speaking, NCTracks only accepts electronic submission of professional claims, either through the NCTracks Provider Portal or as an 837P X12 transaction. The exceptions are only for time limit overrides and Medicare overrides. 

Important things to note are:

  • Field 14 (Date of Current Illness, Injury or Pregnancy) requires a qualifier if a date is submitted. Only qualifier 484 is valid. 
  • Field 15 (Other Date) also requires a qualifier if a date is submitted. Qualifiers 454 and 439 are valid. 
  • Fields 19 and 30 are not used in NCTracks. 
  • Field 21 allows up to 12 diagnosis codes, labeled A-L. 

Diagnosis pointers in Field 24E should correspond to the alpha letter of the diagnosis code in Field 21. Numeric pointers are no longer valid. 

Claims will be rejected in the following circumstances: 

  1. ICD-10 diagnosis code is submitted prior to the ICD-10 effective date
  2. An old 1500 form version is submitted
  3. Provider submits a mix of ICD-9 and ICD-10 diagnoses codes on the same claim 

The 1500 paper claim form does not affect professional claims submitted through the NCTracks Provider Portal or 837 X12 transactions. 

For more information regarding the 1500 form, see the NUCC website at http://www.nucc.org/.