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Nov 18, 2014 - On August 1, 2014, Mississippi Medicaid will begin receiving and processing paper claims submitted only on the revised CMS-1500 Claim Form (version 02/12). The revised CMS-1500 (02/12) replaced the former CMS-1500 (08/05). Use of the revised form was required as of April 1, 2014. A sample form is attached for yourJan 6, 2014 - Mar 13, 2014 - Nov 26, 2013 - Form #. CMS 1500. Form Title. Health Insurance Claim Form. Revision Date. 2012-02-01. O.M.B. #. 0938-1197 2020-03-31. CMS Manual. N/A. Special Instructions. Starting April 1, 2014 only the revised, 02-12 version will be accepted. The 1500 claim form (AKA – HCFA 1500 or CMS. 1500) is developed by the a 2-byte qualifier. • Valid qualifiers are provided in the 02/12 Instruction Manual The 1500 claim form (AKA – HCFA 1500 or CMS. 1500) is developed by the a 2-byte qualifier. • Valid qualifiers are provided in the 02/12 Instruction Manual Items 14 - 33 -