NAC686A.288. Forms for submission of claims.

     1. The payer of a claim under a contract for health insurance:

     (a) Shall accept a claim submitted on a form that:

          (1) Has been approved by the United States Department of Health and Human Services for the filing of a claim under a contract for health insurance; and

          (2) Contains the information necessary to constitute a clean claim.

     (b) Shall not require the completion of any other form for the purpose of processing the claim.

     2. For the purposes of this section, a “form that has been approved by the United States Department of Health and Human Services” means:

     (a) For claims submitted by a hospital or other institutional provider, Centers for Medicare and Medicaid Services Form CMS-1450, which is commonly referred to as UB-04, or its successor form; and

     (b) For claims submitted by a health care practitioner or other person entitled to reimbursement, Centers for Medicare and Medicaid Services Form CMS-1500, or its successor form.

     3. Form CMS-1450, also known as the UB-04 claim form, published by the National Uniform Billing Committee, is available from the American Hospital Association on the Internet at http://aha.org/, by telephone at [phone], or by mail at 155 North Wacker Drive, Chicago, Illinois 60606, at the price of $46 for members and $56 for nonmembers. Copies of the form may also be available through office supply stores.

     4. Form CMS-1500, published by the National Uniform Claim Committee, is available from the United States Government Printing Office on the Internet website http://bookstore.gpo.gov, by mail at P.O. Box 979050, St. Louis, Missouri 63197-9000, or by toll-free telephone at [phone], at the price of $29. Copies of the form may also be available through local printing companies and office supply stores.

     (Added to NAC by Comm’r of Insurance by R175-01, eff. 5-23-2002; A by R026-12, 9-14-2012)