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Claim
| Block # | fill in |
|---|---|
| Block 1 | Insurance |
| Block 1a | Medicare Health Insurance Claim # |
| Block 2 | Pt first name, last, as shown on card |
| Block 3 | Eight digit birth date ,sex |
| Block 4 | Name of insured, if pt write same, if medicare primary leave blank. |
| Block 5 | Pt address, and telephone. |
| Block 6 | Relationship to insured |
| Block 7 | The insured address, if pt write same,complete only after 4,6,11 |
| Block 8 | LEAVE BLANK |
| Block 9 | Write name of medigap enrollee , if same on block 2 write same, if no Medigap leave blank |
| Block 9a | Policy & Group # of Medigap |
| Block 9b | LEAVE BLANK |
| Block 9c | Leave blank if 9d is filled out. if not, write abrev st address, two letter postal and zip. Ex: 1234 Park Ave, NY 20072 |
| Block 9d | Write in COB agreement Medigap based identifier. |
| Blocks 10a-c | Check yes or no, employment, accident (Auto , Other) |
| Block 11 | Determines whether Medicare is primary |
| Block 11a | Insured birth goes, enter sex if different than block 3 |
| Block 11b | Employer name or change in ins status |
| Block 11c | 9 digit # of primary insurer |
| Block 11d | LEAVE BLANK |
| Block 12 | Signature release of info |
| Block 13 | Signature to authorize payment |
| Block 14 | 6 or 8 digit date of current illness, injury, pregnancy. |
| Block 15 | LEAVE BLANK *except if prov is seeing pt in facility |
| Block 16 | req w/ workers comp. Date pt is unable to work |
| Block 17 | referring / ordering Phd |
| DN | Referring Prov |
| DK | Ordering Prov |
| DQ | Supervising Prov |
| Block 17a | LEAVE BLANK |
| Block 17b | NPI # |
| Block 18 | hospitalization dates 6-or8 digit. |
| Block 19 | date when pt was last seen, NPI of attending physician |
| Block 20 | Mark yes if labs were done .if multiple each should be on seperate claim. |
| Block 21 | Dx codes ICD-10 |
| Block 22 | LEAVE BLANK |
| Block 23 | Prior authorization # |
| Block 24a | DOS |
| Block 24b | Place of service Code |
| Block 24c | Medicare prov dont have to fill out |
| Block 24d | Enter procedure code (CPT codes) |
| Block 24e | Diagnosis Pointer |
| Block 24f | Enter prov billed charges |
| Block 24h | LEAVE BLANK |
| Block 24I | Enter ID qualifier 1C in the shaded portion |
| Block 24j | Rendering Prov NPI in the unshaded portion |
| Block 25 | Enter prov or supplier federal ID # or SSN |
| Block 26 | Enter pt account # |
| Block 27 | Accepts assignments of Medicare benefits |
| Block 28 | Enter total charges |
| Block 29 | Enter total amnt the pt paid for covered serv |
| Block 30 | LEAVE BLANK |
| Block 31 | Signature of provider of an authorized |
| Block 32 | Enter the name ,address,zip, where serv rendered |
| Block 32a | Enter NPI of facility of the medicare policy |
| Block 33 | The prov billing address , zip code, telephone # |
| Block 33a | The NPI of billing prov or group |
Created by:
Laura.correa
Popular Health & Social Care sets