Easily Insert Initials Field to the Accident Medical Claim Form

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How to Insert Initials Field to the Accident Medical Claim Form

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In this video tutorial, the process of completing a HICFA 1500 claim form for non-institutional health care providers is explained. The majority of claims are submitted electronically, but secondary claims are submitted on paper along with the primary Explanation of Benefits (EOB). The example claim is for a patient named Edna, detailing the completion of specific boxes: Box 1 is filled with "Other" for commercial insurance; Box 2 contains the patient’s name; Box 3 includes the patient’s date of birth and gender; Box 5 captures the patient’s address and phone number; and Box 6 indicates the patient relationship as "self." Additional information about insurance benefits is also addressed.

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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 the field 11 in CMS 1500 claim form?

KEY: R = Required | NR = Not Required | S = Situational, only use if appropriate specific to claim Field IDField DescriptionData Type10dCLAIM CODES (DESIGNATED BY NUCC)S11INSUREDS POLICY GROUP OR FECA NUMBERNR11aINSUREDS DATE OF BIRTH, GENDERNR11bOTHER CLAIM ID (DESIGNATED BY NUCC)NR59 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.

How do I fill out a 1500 claim form?

How to fill out a CMS-1500 form The type of insurance and the insureds ID number. The patients full name. The patients date of birth. The insureds full name, if applicable. The patients address. The patients relationship to the insured, if applicable. The insureds address, if applicable. Field reserved for NUCC use.

How many fields are there in the CMS 1500 form?

There are 33 boxes in a CMS-1500 form. All of these boxes must be filled for the insurance claim to pass through. Lets take a look at all the boxes or fields step by step.

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 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 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 box 9 in CMS 1500?

NOTE: Box 9d on the HCFA / CMS 1500 form is where the Secondary Insurance for a patient populates.

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.

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Insert Initials Field to the Accident Medical Claim Form