ComplyRight CMS-1500 Health Insurance Claim Form (02/12), 1000/Carton (CMS12LC1)
$24.49
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ComplyRight CMS-1500 Health Insurance Claim Form (02/12), 1000/Carton (CMS12LC1)

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Item #: 116719 Model #: CMS12LC1
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Highlights
  • Approved by the National Uniform Claim Committee (NUCC); HIPAA compliant
  • The most significant change was the addition of 8 diagnosis codes in field 21
  • Includes new QR code identifier at the top of the form that supports and aligns with Industry scanning systems
$24.49
1000/carton
Next-Day eligible
if you Order within 8 hrs 49 mins

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About this product

This 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)

  • Approved by the National Uniform Claim Committee (NUCC); HIPAA compliant
  • The most significant change was the addition of 8 diagnosis codes in field 21
  • Includes new QR code identifier at the top of the form that supports and aligns with Industry scanning systems
  • Printed with OCR "dropout" red ink on 20lb. paper (per government regulations)
  • Form not available personalized
  • Certified Chain of Custody; promotes sustainable forest management
  • Size: 8-1/2 x 11"
  • 1,000 per carton
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