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1500 Instructions and Claim Form Request Form Final

The document outlines the criteria and procedures for submitting change requests for the 1500 Claim Form and its accompanying instructions, emphasizing the need for national relevance and minimal impact on current users. It details the responsibilities of the requester, including providing thorough documentation to support their request. Additionally, it notes that revisions to the form occur infrequently and that denied requests cannot be resubmitted for one year.

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12 views3 pages

1500 Instructions and Claim Form Request Form Final

The document outlines the criteria and procedures for submitting change requests for the 1500 Claim Form and its accompanying instructions, emphasizing the need for national relevance and minimal impact on current users. It details the responsibilities of the requester, including providing thorough documentation to support their request. Additionally, it notes that revisions to the form occur infrequently and that denied requests cannot be resubmitted for one year.

Uploaded by

gracesachinrock
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Change Request Form for 1500 Claim Form and Instructions

PLEASE REVIEW THE 1500 CLAIM FORM AND INSTRUCTIONS CRITERIA IN ITS ENTIRETY BEFORE
COMPLETING THE REQUEST FORM.

Questions about the 1500 Claim Form and 1500 Reference Instruction Manual can be emailed to
[email protected]. The request form is not needed to ask questions.

1500 CLAIM FORM REQUEST CRITERIA

The following criteria are used by the NUCC when considering requests for changes to the 1500 Claim
Form.
Note: Revisions to the 1500 Claim Form occur infrequently (e.g., every 5 – 10 years) if at all due to the
impact on the industry to implement a revised form. Requests for changes to the form will be reviewed
and held until the next potential revision. In addition, form space constraints limit the ability to
accommodate requests for revision.

 Data being requested has been added to the X12 Health Care Claim: Professional (837P)
electronic transaction.
 The need to report the data is national and not local or state specific.
 The change to the form will not significantly impact current users.
 The request includes specific information on how the current form is negatively impacting claims
processing or adjudication.
 The proposed change is within the scope of work being done to revise the form. (The NUCC may
limit the scope of changes it will consider during a revision of the form, based on industry
feedback of the impact of implementing the changes.)

1500 INSTRUCTIONS REQUEST CRITERIA

The following criteria are used by the NUCC when considering requests for changes to the 1500
Reference Instruction Manual.

 The instruction for reporting the data aligns with data reported in the X12 Health Care Claim:
Professional (837P) electronic transaction.
 The need for the instruction is national and not local or state specific.
 The change to the instructions will not significantly impact current users of the instructions.
 The request includes specific information on how the current instructions are negatively
impacting claims processing or adjudication.
 The request is to clarify current instructions.
NUCC REVIEW OF REQUESTS

The applicant is responsible for submitting appropriate information and documentation that
demonstrates the need for the change to the 1500 form or instructions. During its review, the NUCC
may, but is not required to, complete independent research, which it may share with the requester.

ADDITIONAL INFORMATION

 Updated versions of the 1500 Claim Form Reference Instruction Manual are released yearly on
July 1.
 Any changes, clarifications, and errata for the instructions are posted to the NUCC website, at
www.nucc.org under the 1500 Claim Form tab, with the issue and effective date of the change.
 Revision of the 1500 Claim Form is done infrequently (e.g., every 5 – 10 years) due to the impact
on the industry to implement a revised form. Information will be posted on the NUCC website
when the form is under review for revision.
 If a request for a change is denied, the requester may not submit a new request for the same or
substantially similar change for a period of one (1) year from the date of denial.

INSTRUCTIONS FOR SUBMITTING REQUESTS

1. After reading the 1500 Claim Form and Instructions Criteria, complete all sections of the form
and be as thorough as possible explaining the request.
2. Include specific information and documentation that supports the need for the change and how
the criteria are met. Requests lacking supporting information or documentation will be
returned to the requester and will not be reviewed by the NUCC until the necessary information
or documentation, as the case may be, is provided.
3. Submit completed forms to [email protected].
Change Request Form for 1500 Claim Form and Instructions

Date:
Requester Name or Organization: Requester Contact Information:

Is the request for a change to the form or instructions?

_____ Form _____ Instructions

Describe the change being requested. Include information that explains how the change will:
 Align with the X12 Health Care Claim: Professional (837P) electronic transaction (instruction
revisions),
Or
Align with new data added to the X12 Health Care Claim: Professional (837P) electronic
transaction (Form revisions),
 Meet a national need and not local or state specific need,
 Not significantly impact current users of the form or instructions, or
 Not impact current claims processing or adjudication.

Explain the reason for the request, such as why the current form or instruction is inadequate or what
new item needs to be accommodated.

Provide proposed language for the instruction change.

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