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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 BlueCross BlueShield of Western New York.

BlueCross BlueShield of Western New York will only accept the CMS-1500(02/12). Providers submitting an invalid claim form will have their claims rejected and sent 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, www.nucc.org, under the ‘1500 Claim Form’ tab. BlueCross BlueShield of Western 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 ASK-EDI section


Ordering Forms and Submitting Claims:

There are several ways to order CMS-1500 forms:

  1. Contact your current forms supplier
  2. Visit the Government Printing Office online: https://bookstore.gpo.gov/catalog/government-forms-phone-directories/government-forms/health-medical-forms
  3. Call 888-512-1800
     

Submitting a Claim: 

All paper claims should be submitted to:
BlueCross BlueShield of Western New York
P.O. 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.

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