Cms 1500 Claim Filing Instructions (Page 2 of 9) in pdf

Cms 1500 Claim Filing Instructions Page 2

Relationship of the patient to the subscriber. Check “other” if

relationship is not self, spouse, or child of the subscriber.

Required

Insured’s Address (No., Street)

Street and house/apartment # of the subscriber. Address may

include post office box or street name and number, city, state, zip

code and phone number.

Not Required

Patient Status

Indicates whether the patient is single, married, employed, full or

part-time student or other.

Required if

Other Insured’s Name (Last Name, First Name, Middle Initial)

applicable

Name of the subscriber of other coverage if the patient is covered

on another policy either outside or within this Plan.

Required if

Other Insured’s Policy or Group Number

applicable

Policy, certificate, or group number of an additional policy of

coverage.

Required if

Other Insured’s Date of Birth, Sex

applicable

Date of birth of the subscriber of an additional policy of coverage.

Required for

Employer’s Name or School Name

Federal

Employer’s name or school name of an additional policy of

Employee

coverage.

Program (FEP)

if applicable

Required for

Insurance Plan Name or Program Name

FEP if

Company name or group name of the additional coverage.

applicable

Cms 1500 Claim Filing Instructions Page 2