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Insert Smart Field in the Accident Medical Claim Form

Insert Smart Field in the Accident Medical Claim Form

Aug 6th, 2022

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How to Insert Smart Field in the Accident Medical Claim Form

4.6 out of 5

33 votes

In today's video, the tutorial focuses on completing a HICFA 1500 claim form for non-institutional healthcare providers to submit claims. While the presenter usually submits claims electronically, secondary claims will be filed on paper with the primary EOB. The video demonstrates filling out various boxes: Box 1 is for insurance type, selecting "Other" for commercial policies; Box 2 is for the patient's name; Box 3 includes the patient's date of birth and gender; Box 5 contains the patient's address and phone number; Box 6 indicates the patient’s relationship, which is self in this case. The presenter explains that if the patient has a different insurance policyholder, that information would be entered instead. Box E is for noting if there is another health benefit plan.

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 is field 12 in CMS 1500?

12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

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 the field 11 in CMS 1500 claim form?

The street address, area, state, ZIP code, and telephone number are included. Box 11: This field requires the insureds policy or group number to be filled.

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 the field 23 in CMS 1500 claim form?

KEY: R = Required | NR = Not Required | S = Situational, only use if appropriate specific to claim Field IDField DescriptionData Type22RESUBMISSIONNR23PRIOR AUTHORIZATION NUMBERNR24SHADED AREA SUPPLEMENTAL INFORMATION24aDATE(S) OF SERVICER59 more rows

What information goes into Block 11 of CMS claim form?

item 11. Enter the employers name, if applicable. If there is a change in the insureds insurance status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word RETIRED.

What is field 9 in CMS 1500 claim form?

9. Name of the INSURED PERSON of other payer in Insurance Information screen under Patient Master.

What fields are required on CMS 1500?

CMS 1500 Sample Claim Form and Instructions Type of health insurance coverage applicable to this claim check appropriate box. Patients Name. Patients Birth Date/Sex. Insureds Name (Same or leaving blank is not acceptable.) Patients Address. Patients Relationship to Insured.

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