Easily Insert Amount Field into the Accident Medical Claim Form

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How to Insert Amount Field into the Accident Medical Claim Form

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In this video tutorial, the presenter demonstrates how to complete the HICFA 1500 claim form, which is used by non-institutional healthcare providers for claims submission. They primarily submit claims electronically but explain the process for submitting a secondary claim on paper. The example provided involves a patient named Edna. Key steps include: selecting "Other" in Box 1 for commercial insurance, filling in the member ID, and entering the patient's name, date of birth, gender (Box 2 and 3), and address with phone number (Box 5). Box 6 indicates the patient relationship, noted as "self" in this case. If there were a different policyholder, their information would be entered instead. The video also touches on including other health benefit plans if applicable.

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What goes in box 23 on the CMS 1500 form?

Box 23 - TITLE: Prior Authorization Number (this field is also used for CLIA numbers) INSTRUCTIONS: Enter any of the following: prior authorization number, referral number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service.

What is field 19 in CMS 1500 claim form?

Box 19 is commonly used on paper claims for data not otherwise accommodated by the CMS-1500 claim form. Data entered in this field will print but will NOT export electronically. Please contact your payer to determine where the data is expected.

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 field 23 in CMS 1500 claim form?

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

What is field 22 in CMS 1500 claim form?

Complete box 22 (Resubmission Code) to include a 7 (the Replace billing code) to notify us of a corrected or replacement claim, or insert an 8 (the Void billing code) to let us know you are voiding a previously submitted claim. Enter the Blue Cross NC original claim number as the Original Ref.

What is field 17 on a claim form?

Information about Item 17 (Name of Referring Provider or Other Source) Item 17 of the CMS-1500 (02-12) claim form is reserved for the Referring Provider or Other Source. ing to the. National Uniform Claim Committee, NUCC, if multiple providers are involved, enter one provider in the following.

What is field 17 in CMS 1500 claim form?

Box 17 - Name of Referring Provider or Other Source Enter the applicable qualifier to identify which provider is being reported. Enter the qualifier to the left of the vertical, dotted line.

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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Insert Amount Field into the Accident Medical Claim Form