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Insert Name Field to the Accident Medical Claim Form

Insert Name Field to the Accident Medical Claim Form

Aug 6th, 2022

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How to Insert Name Field to the Accident Medical Claim Form

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In today's video tutorial, the presenter demonstrates how to complete a HICFA 1500 claim form, utilized by non-institutional healthcare providers for claim submissions. The tutorial covers the electronic submission of claims, with a focus on secondary claims submitted on paper. The example provided involves a claim for a patient named Edna, highlighting the completion of specific fields: Box 1 for insurance type (selected as 'other' for a commercial policy), Box 2 for the patient's name, Box 3 for the patient's date of birth and gender, Box 5 for the patient's address and phone number, and Box 6 for the patient relationship (noting it as self). If there were a different policyholder, their information would be included accordingly. The tutorial continues with insurance plan details in Box E.

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 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 23 in CMS 1500 claim form?

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

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 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

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.

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.

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 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.

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