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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 health care providers to submit claims. The majority of claims are submitted electronically, but secondary claims may be submitted on paper alongside the primary Explanation of Benefits (EOB). The example provided is for a patient named Edna, with type of insurance indicated as "other" in box 1, indicating a commercial policy. The form is filled with Edna's member ID, name (box 2), date of birth and gender (box 3), address and phone number (box 5), and relationship (box 6), where it is noted that she is self-insured. If there was a different policyholder, their information would be included instead. The video also touches upon identifying any other health benefit plans in box 7.
