Revised CMS 1500 Paper Claim Form: Version 02/12

As of April 1, 2014, Providers should be following Medicaid billing guidelines and have started using the revised CMS 1500 Version 02/12 Paper Claim form. To help providers through this transition, claims received prior to May 31, 2014 on the old claim form will be processed for payment.

Please refer to the NUCC website at for more information and instructions on completing the form.

Please note: Claims received on or after June 1, 2014 on the old claim form is subject to denial.

Information current as of: 08/30/19