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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 to submit claims. The majority of claims are submitted electronically; however, secondary claims may be submitted on paper with the primary Explanation of Benefits (EOB). The example provided is for a patient named Edna. The presenter explains how to fill out various sections: Box 1 is for insurance type, selecting "other" for a commercial policy; Box 2 is for the patient’s name; Box 3 includes the patient’s date of birth and gender; Box 5 requires the patient’s address and phone number; and Box 6 indicates the patient’s relationship. For this example, Edna is self-insured. Information is entered accordingly, and the presenter notes the process for a different policyholder if applicable.
