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The submission of the filled up claim form, along with the required mandatory documents, is not to b

The submission of the filled up claim form, along with the required mandatory documents, is not to b 2025

The submission of the filled up claim form, along with the required mandatory documents, is not to b Preview on Page 1

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The document is a Critical Illness Claim Form for PNB MetLife, outlining the necessary instructions and requirements for submitting a claim. It emphasizes that submission does not imply liability acceptance by the company and highlights the importance of providing complete information and mandatory documents to avoid processing delays. The form collects personal details of the insured, medical history, payment information, and includes a declaration section. It also lists specific critical illnesses covered and mandates signatures from witnesses and declarants.

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What goes in box 32b on a HCFA?

Box 32b is used to indicate the non-NPI identification number of the service facility as assigned by the payer for the facility. Enter the 2-digit qualifier followed by the ID number.

What goes in box 33B on CMS-1500?

Item 17a - Enter the CMS assigned UPIN (the NPI will be used when implemented) of the referring/ordering physician listed in item 17. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 must be used for each ordering/referring physician.

What does field 33 in CMS 1500 for denote?

33 Required Billing Provider Info Phone # (Pay-To) - Enter the provider name. Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number.

What goes in box 33B on HCFA 1500?

Box 33B: By default, this box will remain blank; however, if a particular payer wants to see a separate provider ID number in that box, you can add it, by the provider, for that particular payer.

What goes in box 17a on a 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.

What is block 33 of the CMS 1500 claim?

Box 33 is used to indicate the name and address of the Billing Provider that is requesting to be paid for the services rendered. Enter the name, address, city, state, and ZIP code.

The submission of the filled up claim form, along with the required mandatory documents, is not to b 2025

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