you thought you had it down pat and realized that
filing dental procedures with medical carriers
wasn’t really so difficult, I have to report
that there is going to be a change. "Change"
– the very word can strike fear in us. There
is one thing in life, and in dentistry, that is
a constant and that is change. So let’s
make the most of this and work through the process.
You will see that there is nothing to fear.
Medical claims have been printed on CMS-1500
forms for the past fifteen years. The form is
actually called CMS-1500 (12/90). We are all aware
of the many changes that have taken place in medicine
in that time period. Add to that the requirements
of HIPAA and you will, no doubt, realize that
the manner in which we will be asked to communicate
with insurance carriers through a claim form will
have to be revised.
The new form is still be referred to as CMS-1500
but the update name is CMS-1500 (08/05). The primary
impetus for the revision is HIPAA. As I am sure
you are aware, all medical providers will be required
to report their NPI (National Provider Identifier)
on all claim forms. In order to accommodate for
the HIPAA requirements, the form has to provide
fields for entering this information. There are
also some other changes that can make filing a
little easier and I will discuss these toward
the end of the article.
You may ask what the timeline is on this change.
According to Ingenixonline, ‘as of January
2, 2007 all Health plans, clearinghouses and other
information support vendors will be ready to handle
and accept the revised form". Between that date
and March 30, 2007, all providers will be allowed
to file on either form as there will be a dual
acceptability period. Effective with April 2,
2007, the older claim form will be discontinued
and all claims will have to be reported on the
revised form. Do not assume that the old form
can be used if you are submitting a claim after
that date but with a date of service prior to
April 2, 2007. Resubmitted claims must be filed
on the revised claim form. The only exception
to these rules is for small health plans. They
will be required to accept the revised form no
later than May 23, 2008.
In addition to entering the provider’s
NPI, you will also need to provide a referring
provider’s ID number including the ID Qualifier.
Your staff should obtain these numbers when the
referral is made.
With the current version of CMS-1500 (12/90),
providers have been entering either PINs (Provider
Identification Numbers), UPINs Unique Physician
Identification Numbers, OSCARs (Online Survey
Certification & Reporting System numbers)
or NSCs (National Supplier Clearinghouse numbers).
They are commonly referred to as legacy identifiers.
The CMS-1500 (08/05) has been revised to accommodate
the NPIs, and the major change is that there are
split provider ID fields. The split field is required
to enable the reporting of the NPI and/or the
legacy identifiers during the dual acceptability
Let’s look at the individual changes on
- Field 17 – The old form required the
name of the referring physician with the referring
physician’s ID number listed in 17a. The
new field 17 still requires the name of the
referring or ordering provider but 17a has been
split in half length-wise and shaded while 17b
is a new field in the lower half of field 17.
Prior to May 23, 2007, either the legacy ID
number can be placed in 17a, the NPI can be
placed in 17b, or both can be entered. After
that date, only 17b (the unshaded area) is to
- Field 24 - Field 24i and 24j on the old form
have been changed. The revised form also has
the area split length-wise with the top half
shaded. 24i is titled ID Qualifier and this
must be completed. As with field 17, the upper
shaded area can be used until May 23, 2007 to
provide for the rendering provider’s ID
qualifier and legacy number. After that date,
do not use the shaded section and only report
the rendering provider’s NPI in the unshaded
- Fields 32 and 33 – The revisions in
these fields will allow for more detailed information
on where services were rendered and where the
provider of the service is located if different
from where the service was performed (e.g. home
health). You will still need to enter the provider’s
or supplier’s billing name, address, and
zip code. The telephone number needs to be placed
at the top of the box with the area code in
the parentheses. ID numbers and NPIs can be
reported in field 32a and 32b. Providers of
service will need to identify the supplier’s
NPI when billing for purchased diagnostic tests.
Field 33 also has the shaded and unshaded sections
used for reporting the billing provider’s
information. Again, the legacy number is entered
in the shaded field 33a and/or the NPI in the
unshaded field 33b until May 23, 2007 when only
the NPI is required.
To simplify this process, just keep in mind
the basic formula for these fields:
- Shaded fields are for legacy numbers
and unshaded fields are for NPIs.
- Between October 1, 2006 and May 23,
2007 – either or both can be reported.
After that date – only place NPIs in unshaded
Let us now explore the other changes of which
some will not even affect how you will fill out
the form. They are as follows:
- The barcode and words "PLEASE DO NOT STAPLE
IN THIS AREA" were removed. There are other
revisions to the form header but they are not
significant enough to mention.
- Field 1 - Tricare has been placed above Champus.
- Field 21 – This field is still used
for ICD-9 (diagnosis) codes. What has changed
is the length of the lines after the decimal.
These lines were extended to accommodate four
bytes. Diagnosis codes are updated every year.
The codes are becoming more complex with the
result that many of the codes now have several
digits beyond the decimal.
- Field 24 – There are four significant
changes to this field.
- The areas that are used to report procedure
codes have been split length-wise with a shaded
area at the top. This area will eventually
be used to provide supplemental information.
Do not use this area to report extra procedures.
- Field 24c used to be titled "type of service".
EMG, that had been the heading for 24i, is
now the title for 24c.
- Field 24d will still be used for CPT/HCPCS
codes. The modifier area has changed and now
allows for four sets of two bytes. This eliminates
the need to split modifiers between multiple
- Field 24e has had a change of name. It
used to be titled "Diagnosis Code". It has
now been changed to "Diagnosis Pointer". Nothing
has changed in how to use this field; it just
has a more accurate title.
Be advised that there are no grace periods after
the May 23, 2007 effective date for NPI reporting.
Claims filed without this information will be
rejected and the rejection code will most likely
be 16 that states "claim/service lacks information
that is needed for adjudication" along with the
rejection code that specifies the missing information.
If you do not already have your NPI, you can learn
more about it and how to obtain it by visiting
on the CMS web site.
If you would like to see the changes made to
the CMS-1500 form, they can be viewed at the National
Uniform Claim Committee’s web site. You
will be able to view the new form and get information
Now that you have this information, you will be
able to file medical claims correctly once the
changes become effective. You will be serving
your patients’ needs by helping them obtain
additional benefits from their health insurance
plan for their medically necessary dental procedures.
This can result in greater case acceptance for