Completing the CMS-1500 Claim Form

Below are the instructions for filling out the CMS 1500 claim form based on our organizations requirements for what we need to have completed and any special rules we may have.


This guide is designed to highlight the fields of the CMS-1500(02/12) Claim form that are required when submitting to BlueShield of Northeastern New York.


BlueShield of Northeastern New York will only accept the CMS-1500(02/12). Providers submitting an invalid claim form will have their claims rejected back to them, advising to submit the proper form.


Please reference the NUCC 1500 Health Insurance Claim Form Reference Instruction Manual, which is available on the NUCC website,, under the ‘1500 Claim Form’ tab. BlueShield of Northeastern New York prefers that providers submit their claims electronically. For more information on how to submit claims electronically, contact your EHR vendor or visit our provider portal,, under the ASK-EDI tab.

Ordering Forms & Submitting Claims

To order CMS-1500 forms, contact:


Submitting Claim: All paper claims should be submitted to:
BlueShield of Northeastern New York
PO Box 80
Buffalo, New York 14240-0080


Form Completion: The following pages detail how to complete the CMS-1500 form.


If you have any questions, please contact your Network Representative.