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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