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Insert Text Fields to the Accident Medical Claim Form

Insert Text Fields to the Accident Medical Claim Form

Aug 6th, 2022

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How to Insert Text Fields to the Accident Medical Claim Form

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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 for submitting claims. The majority of claims are submitted electronically, but secondary claims are done on paper with the primary Explanation of Benefits (EOB). The example provided is for a patient named Edna. The tutorial covers specific boxes on the form: Box 1 is filled with 'Other' for commercial insurance; Box 2 includes the patient's name; Box 3 contains the patient's date of birth and gender; Box 5 provides the address and phone number; Box 6 indicates the patient’s relationship, noted as 'self' in this case. If there were a different policyholder, that information would be input instead. The insurance plan name is also highlighted in the example.

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 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 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 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.

How do I fill out a reimbursement claim form?

How to Fill Care Health Insurance Claim Reimbursement Form Step 1: Fill Out the Details of the Primary Insured. Step 2: Disclose the Insurance History of the Person Filing Claim. Step 3: List Down the Details of the Insured Person Hospitalized. Step 4: Enter the Hospitalization Information.

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 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 field 23 in cms 1500 claim form?

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

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.

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