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In this video tutorial, the presenter demonstrates how to complete a HICFA 1500 claim form, which is utilized by non-institutional health care providers for claim submissions. The majority of claims are submitted electronically, but secondary claims may be submitted on paper with a primary electronic loop block (ELB). The example used is for a patient named Edna, with specific instructions on filling out the form. Box 1 is populated with “Other” for a commercial insurance policy, and member ID is entered. Box 2 requires the patient’s name, while Box 3 includes the date of birth and gender. Box 5 captures the patient’s address and phone number, and Box 6 indicates the patient’s relationship (in this case, self). The presenter emphasizes the importance of entering the appropriate information for the guarantor if the patient is not self-insured. Finally, the insurance plan name is recorded in Box E.
