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Delete Fillable Fileds from the Accident Medical Claim Form

Delete Fillable Fileds from the Accident Medical Claim Form

Aug 6th, 2022

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How to Delete Fillable Fileds from the Accident Medical Claim Form

4.6 out of 5

45 votes

In this video tutorial, the presenter explains how to complete a HICFA 1500 claim form, which is used by non-institutional healthcare providers to submit claims. The majority of claims are submitted electronically, but secondary claims may be submitted on paper with the primary Explanation of Benefits. The example used is for a patient named Edna, with steps outlined for filling in specific boxes. Box 1 is for the type of insurance, indicated as "other" for a commercial policy. Box 2 requires the patient's name, and Box 3 requires the patient's date of birth and gender. Box 5 is for the patient's address and phone number, while Box 6 identifies the patient’s relationship, which is "self" in this example. Further details and steps are provided for completing the form.

Got questions?

Below are some common questions from our customers that may provide you with the answer you're looking for. If you can't find an answer to your question, please don't hesitate to reach out to us.

What information goes into Block 11 of a CMS claim form?

item 11. Enter the employers name, if applicable. If there is a change in the insureds insurance status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word RETIRED.

What fields are on a CMS-1500 form?

Field by Field Explanation Of The CMS-1500 Form a. PATIENT NAME from Patient Master. Patient DOB and SEX from Patient Master. Name of the INSURED PERSON of the destination payer in Insurance Information screen under Patient Master. PATIENT ADDRESS, CITY, STATE, ZIP CODE HOME PHONE from Patient Master.

What is the field 9 in CMS 1500 claim form?

9. Name of the INSURED PERSON of other payer in Insurance Information screen under Patient Master.

What goes in box 17a on CMS-1500?

Box 17a. The Other ID number of the referring, ordering, or supervising provider is reported in 17a in the shaded area. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a.

What is field 12 in CMS-1500?

12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

What is field 23 in CMS 1500 claim form?

Box 23 is used to show the payer assigned number authorizing the service(s).

What is field 11 in CMS 1500?

KEY: R = Required | NR = Not Required | S = Situational, only use if appropriate specific to claim Field IDField DescriptionData Type10cS10dCLAIM CODES (DESIGNATED BY NUCC)S11INSUREDS POLICY GROUP OR FECA NUMBERNR11aINSUREDS DATE OF BIRTH, GENDERNR59 more rows

What is field 24 in CMS 1500 claim form?

A Place of Service (POS) is a field used when completing a CMS 1500 form to submit a claim to insurance. It indicates the location in which the health care service is actually provided.

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