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In this video tutorial, the presenter demonstrates how to complete a HICFA 1500 claim form, which is used by non-institutional healthcare providers to submit claims. While most claims are submitted electronically, the presenter addresses the need for paper submissions for secondary claims alongside the primary Explanation of Benefits (EOB). The example given is for a patient named Edna, with specific guidance on filling out various boxes on the form: Box 1 for insurance type (selecting "other" for commercial policy), Box 2 for the patient's name, Box 3 for date of birth and gender, Box 5 for the address and phone number, and Box 6 for the patient’s relationship (noting it as "self" in this case). If there was a different policyholder, their information would be entered instead. Additional details related to insurance and health benefit plans follow.
