CMS 1500 Form
OMB Approved

The form was revised to align the paper form with some of the changes in the electronic Health Care Claims: Professional (837), 005010X222 Technical Report Type 3 (5010) and 005010X222A1 Technical Report Type 3 (5010A1).

Centene health plans, including Cenpatico, began accepting claims on the new CMS-1500 claim form (version 2/12) on January 6, 2014.

Between January 6 and March 31, 2014 Centene/Cenpatico will accept claims on both form versions: the new form, (CMS- 1500, version 2/12) OR the current form (CMS-1500, version 8/05).

Effective 4/1/2014 only the new version, CMS-1500 2/12, will be accepted. Claims submitted on the old form version (CMS-1500/08/05) will be rejected if received on or after 4/1/2014.

• The form can now accommodate 12 diagnoses instead of 4.
• The client's marital and employment status (Box 8), the insured's employer or school name (Box 11b), and "Other Insured's Date of Birth, Sex, and Employer" (Box 9b and 9c), and "Balance Due" box (Box 30) has been deleted.
• Box 21, Diagnosis or Nature of illness or Injury, you'll see "ICD Ind." to identify whether the diagnosis is from the ICD-9 (write "9") or ICD-10 (write "0"). The ICD Indicator will be important as providers transition to the ICD-10. The DSM-5 lists both ICD-9 and ICD-10 code sets. ICD-10 codes are to be used effective 10/1/2014.
• The DSM-5 no longer has multi-axial diagnosis, (Axis I-V) Instead, diagnoses are simply listed. Axis IV (Psychosocial and Environmental Problems) has been eliminated. These are now represented by ICD-9 V codes and ICD-10 Z codes. Since the DSM is NOT a coding system for billing, providers must select the appropriate ICD codes.

Cenpatico providers will need to purchase the new CMS-1500 (02/12) form. As with the prior form version, only the original red ink form will be accepted. Handwritten forms are not acceptable. If providers are filing electronically, they will need to ensure that their claims software, the billing service or clearinghouse align with the new form.

Cenpatico providers will need to purchase the new CMS-1500 (02/12) form. As with the prior form version, only the original red ink form will be accepted. Handwritten forms are not acceptable. If providers are filing electronically, they will need to ensure that their claims software, the billing service or clearinghouse align with the new form.