Cms 1500 Word Scramble
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Question | Answer |
Block1. | Medicare box |
Block1a | Insurance ID number |
Block2. | Patient name (last name, first name, Middle initial) |
Block3. | patient birth date/sex |
Block4. | Insurance name (last name, first name, middle initial) |
Block5 | Patient address , city, state , zip code, Telephone |
Block6. | Patient relationship to insured |
Block7. | Insurance address , city, state, zip code, telephone |
Block8. | Reserved for Nucc use |
Block9. | other insured name (last name, first name, middle initial) |
block9a. | Other insured policy or group number |
block9b. | Reserved for NUCC use |
block9c. | Reserved for NUCC use |
block9d. | Insurance plan name or program name |
Block10 | is the patient condition related to |
Block10a | employment |
Block10b | auto accident |
Block10c | other accident |
Block10d | |
Block11 | insurance policy group of feca number |
Block11a | insurance date of birth / sex |
Block11b | other claim |
Block11c | insurance plan name or program name |
Block11d | another health benefits plan |
Block12 | patient or authorized person signature |
Block13 | insurance or authorized person signature |
Block14 | dates of current illness, injury pregnancy |
Block15 | other date |
Block16 | dates patent unable to work |
Block17 | leave blank |
Block18 | hospital date related to current service |
Block19 | leave blank |
Block20 | |
Block21 | diagnosis or nature of illness or injury |
Block22 | Resubmission number |
Block23 | Prior authorization number |
Block24a | dates of service |
Block24b | place of service |
Block24c | Emg |
Block24d | Procedures service or supplies |
Block24e | Diagnosis pointer |
Block24f | $ charges |
Block24G | Days or units |
Block24H | EPSDT |
Block24I | ID qual |
Block24J | Rendering provider ID |
Block25 | Federal Tax I.d number |
Block26 | patients account NO. |
Block27 | accept assignment |
Block28 | total charge |
Block29 | amount paid |
Block30 | Rsvd for Nucc use |
Block31 | Signature of physician or supplier includes degrees credential |
Block32 | service facility location information |
Block33 | Billing provider information & ph # |
Created by:
Jackie_20
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