New CMS-1500 claim form to replace Michigan Status Claim Review Form

As you’ve read in previous issues of The Record, BCBSM will begin accepting the revised CMS-1500 claim form (version 02/12) on Jan. 6, 2014. It replaces version 08/05, as well as the Michigan Status Claim Review Form.

We’ll no longer accept the 08/05 version of the CMS-1500 claim or the Michigan Status Claim Review Form as of April 1, 2014.

The Michigan Status Claim Review Form was used when a claim was rejected or if the payment received was different from what was anticipated — issues you’ll be able to address with the new CMS-1500 claim. Following are the fields that will need to be completed when submitting a claim status update:

Field 22: This field takes the place of the Michigan Status Claim Review Form. (If you’re submitting a new claim, leave this field blank.) List the original reference number for resubmitted claims. When resubmitting a claim, enter the appropriate bill frequency code left-justified on the left-hand side of the field.

Field 19: This is required on a resubmitted claim. If you complete Field 22, you must complete Field 19 as well, providing additional information.

As of Jan. 6, 2014, you can get more details about the above-mentioned fields or learn about other changes to the CMS-1500 claim in the “Claims” chapter of your provider manual.

You’ll be able to order the new claim form (version 02/12) from us beginning Jan. 1, 2014, by completing the Facility and Professional Supply Requisition Form. There are two ways to access the form:

1) You can access it via your provider manual on Explainer.

• From web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Click on Provider Type and select yours from the “Make Selection” box.
• Click on the Search button and then on the Blue Pages Directory chapter.
• Click on Forms and supplies and then on Facility and Professional Supply Requisition.
• Print and complete the form and mail it, along with a check for the total amount of your order, to the address provided on the form.

2) You can access it via the BCBSM Newsletters and Resources page on bcbsm.com/providers.

• From web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Facility and Professional Supply Requisition Form, which you can access from the list of frequently used forms on the right side of the screen.
• Print and complete the form and mail it, along with a check for the total amount of your order, to the address provided on the form.

For more information about the new CMS-1500 claim form, see the December 2013 Record, contact your provider consultant or visit NUCC.org**.

**BCBSM does not control this website or endorse its general content.