Easily Replace Fileds into the Accident Medical Claim Form

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How to Replace Fileds into the Accident Medical Claim Form

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How to fill out a CMS 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 box 17 on HCFA?

What is it? Box 17 identifies the name of the referring provider on the claim. Enter the applicable qualifier to the left of the vertical dotted line to identify which provider is being reported.

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 field 17 on a claim form?

Information about Item 17 (Name of Referring Provider or Other Source) Item 17 of the CMS-1500 (02-12) claim form is reserved for the Referring Provider or Other Source. ing to the. National Uniform Claim Committee, NUCC, if multiple providers are involved, enter one provider in the following.

What is field 26 in CMS 1500 claim form?

ID Qualifier - Enter X if billing for emergency services. 26 optional Patients Account Number -Enter the patients medical record number or account number in this field.

What is field 19 in CMS 1500 claim form?

Box 19 is commonly used on paper claims for data not otherwise accommodated by the CMS-1500 claim form. Data entered in this field will print but will NOT export electronically. Please contact your payer to determine where the data is expected.

What is field 32 in CMS 1500 claim form?

Item 32 - For services payable under the physician fee schedule and anesthesia services, enter the name and address, and ZIP code of the facility if the services were furnished in a hospital, clinic, laboratory, or facility other than the patients home or physicians office.

What is field 17 on the CMS 1500?

An entry in this field may indicate employment related insurance coverage. Item 17 - Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data.

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