Paper Claims Submitted on Outdated CMS-1500 (08-05) Claim Forms Will Be Returned

Palmetto GBA Railroad Medicare continues to receive paper claims submitted on the old CMS-1500 (08/05) version claim form. As a reminder, the Centers for Medicare & Medicaid Services (CMS) mandated that as of April 1, 2014, Medicare can only accept paper claims submitted on the revised CMS-1500 (02/12) version claim form. If you are submitting claims on old CMS-1500 forms, your claims will be returned to you. Prior to September 1, 2015, claims submitted on CMS-1500 (08/05) forms were rejected with remittance remark code N34 - Incorrect claim form/format for this service. Rejected claims do not have appeal rights.

We also continue to receive both old and new paper claims from providers who are required to file claims electronically. The Administrative Simplification Compliance Act (ASCA) requires claims to be submitted electronically to Medicare with few exceptions. Paper claims from providers that are required to submit electronic claims, as established by the ASCA review process, will reject with remittance remark code M117 - Not covered unless submitted via electronic claim.  Rejected claims do not have appeal rights. 

Providers who are eligible to submit paper claims should verify the form version they are using before submitting any additional paper claims. If you are not sure which version you are submitting, the claim form version number can be seen in the lower right corner of the form. Find information about ordering the new CMS 1500 (02-12) claim forms.

Alternatives to Paper Claims
If you do not want to purchase new forms or you are tired of submitting paper claims, you may either:

• Refile the claim electronically. If you are not enrolled to file electronically, view our EDI enrollment resources.
• Refile a paperless claim through our eServices eClaims feature. When you use our free eClaims option you will receive confirmation that your claim has been submitted, you can correct and resubmit a rejected claim, and your claim will be processed in 14 days. See the eServices User Manual (PDF) for more information on eClaims.

Note: Before registering for eServices you will need to have an Electronic Data Interchange (EDI) enrollment agreement on file and a claim in history. You do not need a third party vendor.

Avoid CMS-1500 (02-12) Claim Form Rejections! 
Claims with misaligned data slows down the processing of the claim and can cause claim rejections.

The CMS 1500(02/12) form has a number of changed that require significant adjustments to the print layout to ensure proper alignment of data. Providers should be aware of the changes below to avoid claim rejections due to improperly aligned claims.

In item 17, a new qualifier must be used to identify the role of the provider. An appropriate qualifier from the list below must be entered to the left of the dotted vertical line preceding the provider’s name. Medicare will reject claims submitted without a valid provider qualifier.

• DN - referring provider
• DK - ordering provider
• DQ - supervising provider

In item 21,
1. A new indicator is required to indicate the diagnosis code set on the claim. In the 'ICD Ind’ field found in the top right corner of item 21, enter either a 9 to indicate the ICD-9 diagnosis code set or a 0 to indicate the ICD-10 diagnosis code set. Claims submitted without a valid ICD indicator will be rejected.  Note: Both ICD-9 and ICD-10 diagnosis codes cannot be used on the same claim form. 

2. Up to 12 diagnosis codes are now entered on the lines lettered A to L (instead of 1-4) and the lines are read from left to right (instead of up and down). 

Some providers are submitting 02-12 version claims incorrectly with diagnosis codes on lines A, C, I and K only. It appears providers are printing those claims using an old 08-05 version template that is not aligned properly for the new 02-12 form. Medicare will reject claims with diagnosis codes submitted in non-consecutive lines. 

In item 24e, the diagnosis pointer must now be entered using the reference letter (A-L) from item 21 of the corresponding primary diagnosis for the date or service and procedure performed. Some providers are still reporting the diagnosis pointer in item 24e of the 02-12 claim using a number instead of a letter. Medicare will reject claims submitted with a number(s) or with multiple letters in item 24e.  

Other Important Paper Claim Submission Tips
The font should be:

• Legible (computerized or typed claims, laser printers are recommended)
• In black ink
• Courier or Arial in 10, 11 or 12 point font
• Capital letters

The font must not have:

• Dot matrix print 
• Bold, script, italic or stylized font
• Broken characters
• Red ink
• Mini-font

Do not submit paper claims with:

• Liquid correction fluid changes 
• Data touching box edges or data running outside of the numbered boxes 
• More than six service lines per CMS-1500 claim form. Do not compress two lines of information on one line. If more than six service lines are required, see instructions listed below under 'Claims Submitted with Multiple Pages.' 
• Information in the shaded area in 24a through 24h. These fields are not used by Medicare (exception - NDC for physician-administered drugs for Medicare/Medicaid patients). 
• Narrative descriptions of procedure codes, modifiers or diagnosis codes 
• Stickers or rubber stamps 
• Data, mailing address or labels on the top portion of the CMS-1500 claim form 
• Special characters (e.g., hyphens, periods, parentheses, dollar signs and ditto marks) 
• Handwritten descriptions 
• Superbills

The claim form must be:

• An original CMS-1500 printed in red 'drop out' ink with the printed information on back. Photocopies are not acceptable. 
• Size: 8 ½ x 11 with the printer pin-feed edges removed at the perforations 
• Free from excessive creases or tears (do not fold or staple) 
• Clean and free from stains, notations, strike-overs, crossed-out or highlighted information, liquid correction fluid, glue, or tape

Attachment Reminders:

• All attachments must identify the patient’s name, Medicare number, date of service and other pertinent information 
• Attachments must be a full page (8 ½ x 11) 
• Operative reports, radiology reports, etc., should be submitted with paper claims only when either the coding guidelines indicate these reports are needed to process the service(s) or when a Medicare representative requests this additional information. 
• Medicare Secondary Paper claims: Only attach the summary notice from the primary insurer that specifically corresponds to the claim you are submitting

If you have questions, you may contact our Provider Contact Center at 888-355-9165. Representatives are available from 8:30 a.m. to 4:30 p.m. in all time zones with the exception of PT, which receives service from 8 a.m. to 4 p.m. PT.