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MED112 CODE/BILL
MED112 BLOCKS
| BLOCK | DESCRIPTION |
|---|---|
| Block 1 | Box indicating what kind of insurance is applicable, such as medicare |
| Block 1A | Pts medicare health insurance claim number(HICN) Recorded if medicare is primary or secondary (Insured ID#) |
| Block 2 | Pt First Name Middle Initial and last name from medicare card |
| Block 3 | Pt 8 digit Birth date MM/DD/CCYY and sex |
| Block 6 | Pt relationship to the insured |
| Block 8 | Leave Blank |
| Block 9A | Policy and/or group number of the medigap insured preceded by Medigap, MG or MGAP |
| Block 9B | Leave Blank |
| Block 9C | Leave Blank |
| Block 9D | Coordination of Benefits agreement Medigap- based Identifier/ |
| Block 11A | Insured birth date and sex if different from block 3 |
| Block 13 | Signature authorized payment of benefits to the provider or supplier. Signature on file is acceptable here |
| Block 1-13 | Pt information |
| Blocks 14- 33 | Physician information |
| Block 4 | Insured's name (Last Name. First Name, Middle Initial) |
| Block 5 | Pt address |
| Block 7 | Insured Address |
| Block 8 | Pt Status |
| Block 9b | Other Insured Date of Birth and Sex |
| Block 9c | Employer's Name or School Name |
| Block 9d | Insurance plan name or program Name |
| Block 10 | Is Pt condition related to Employment, Auto Accident, Other Accident |
| Block 10d | Reserved for local use |
| Block 11 | Insured's policy Group or FECA Number |
| Block 11a | Insured's Date of Birth Sex |
| Block 11b | Employer's Name or School Name |
| Block 11c | Employer's Name or School Name |
| Block 11d | Is there another health benefit plan (If yes return to 9a-d |
| Block 12 | Patient's or Authorized person's signature to release of any medical or other information necessary to process this claim |
| Block 14 | Date of current illness (First Symptom) Injury(Accident) or PREG |
| Block 15 | If Pt has had same or similar illness. Give first Date |
| Block 16 | Dates Pt unable to work in current occupation from MM/DD/YY to MM/DD/YY |
| Block 17 | Name of referring Provider or other source 17a. 17b.NPI |
| Block 18 | From MM/DD/YY to MM/DD/YY, Hospitalization Dates, Related to current Services |
| Block 19 | Reserved for local use |
| Block 20 | Outside Lab Charges |
| Block 21 | Diagnosis or Nature of illness or injury |
| Block 22 | Medicaid Resubmission Code/ Original Ref. No. |
| Block 23 | Prior Authorization Number |
| Block 25 | Federal Tax ID number SSN EIN |
| Block 26 | Patient account Number |
| Block 27 | Accept Assignment |
| Block 28 | Total Charge |
| Block 29 | Amount Paid |
| Block 30 | Balance Due |
| Block 31 | Signature of Physician or supplier including degrees credentials |
| Block 32 | Service Facility location information a.b. |
| Block 33 | Billing provider info & PH() a.b. |
Created by:
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